A nurse caring for a client who has a prescription for morphine 5 mg IM accidentally administers the whole 10 mg from the single-dose vial. Which of the following actions should the nurse take first?
Report the incident to the pharmacy.
Notify the client's provider.
Measure the client's respiratory rate.
Complete an incident report.
The Correct Answer is C
A. Report the incident to the pharmacy. While the pharmacy may need to be informed, client safety is the priority. The immediate concern is monitoring the client for opioid overdose effects.
B. Notify the client's provider. The provider should be notified, but assessing the client's condition comes first so that the nurse can provide accurate information about any potential adverse effects.
C. Measure the client's respiratory rate. The priority action is to assess the client for signs of opioid toxicity, especially respiratory depression. Morphine can cause decreased respiratory rate, sedation, and hypotension. If the respiratory rate is dangerously low (e.g., below 12 breaths per minute), interventions such as administering naloxone (Narcan) may be necessary.
D. Complete an incident report. An incident report should be completed, but client safety and assessment take priority before documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Dose The dose (5 mg) is clearly stated.
B. Time The prescription does not specify the frequency (e.g., every 4 hours PRN pain). The nurse should clarify how often the medication should be given.
C. Medication The medication (morphine) is clearly stated.
D. Route The route (IV bolus) is clearly specified.
Correct Answer is B
Explanation
A. The client cannot change their mind after signing consent. Clients have the right to withdraw consent at any time before the procedure begins.
B. The alternative treatments to the procedure should be explained. Informed consent includes information about alternative treatments and their risks/benefits so the client can make an informed decision.
C. The time of the procedure should be indicated on the form. The time of the procedure is not a required component of informed consent. The consent form should include the procedure details, risks, benefits, and alternatives
D. The charge nurse should review the form once it's signed. While nurses witness informed consent, they do not validate or review it. The provider performing the procedure is responsible for obtaining consent.
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