A nurse is preparing to administer morphine 4 mg IV bolus to a client who reports pain. Available is morphine 10 mg/mL. Which of the following actions should the nurse take?

Have another nurse witness the disposal of the extra medication.

Discard the extra medication in a sharps container.

Save the extra medication for a later dosing.

Send the waste amount to the pharmacy.

Answer and Explanation

The Correct Answer is A

A.   In many institutions, when a nurse administers a controlled substance and has leftover medication, it is standard practice to have another nurse witness the disposal of the excess. This is a safeguard against misuse and ensures accountability.
B.   While a sharps container is appropriate for disposing of needles and other sharp objects, it is not suitable for liquid medications. Discarding liquid medications in a sharps container could lead to contamination and is not compliant with disposal protocols.
C.   Medications, especially controlled substances, should never be saved for later use once they have been drawn up or prepared. This practice poses a significant risk for medication errors and misuse.
D.   Generally, the waste amount is not sent to the pharmacy. Instead, it should be wasted according to the facility's policy, typically in the presence of another nurse. Sending it to the pharmacy is unnecessary and could create logistical complications.

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Correct Answer is ["A","B","D"]

Explanation

A. This task is appropriate for UAP, as it involves basic hygiene care. UAP can assist with routine oral care
B. Assisting with repositioning is a basic care activity that UAP can perform. This helps prevent pressure ulcers and maintains client comfort, and it does not require advanced clinical skills.
C. Administering IV fluids or medications requires specialized training and knowledge of nursing assessments, potential complications, and monitoring. This task should only be performed by a licensed nurse, not by UAP.
D. UAP can document basic measurements such as urine output. This is a straightforward task that does not require clinical judgment, but the UAP should understand how to accurately measure and record this information.
E. While UAP can observe and report general changes, monitoring for clinical indications of dehydration requires nursing assessment skills and judgment. This task should be performed by an RN, as it involves interpreting signs and symptoms.
F. UAP can weigh clients, but the assessment of weight trends requires clinical judgment and interpretation of data. The RN should evaluate and interpret this information to determine its significance in the client's care.

A. Bradycardia B. Constipation C. High fever D. Pain

Correct Answer is D

Explanation

A. Bradycardia, or a slow heart rate, is not a typical finding during a sickle cell crisis. In fact, during a crisis, the child may exhibit tachycardia (increased heart rate) due to pain, stress, and potential hypoxia.
B. While constipation can be a complication in children with sickle cell disease (often related to pain medications or dehydration), it is not a primary symptom of a sickle cell crisis itself. The immediate concerns in a crisis are related to pain and vaso-occlusive episodes.
C. High fever is not a direct symptom of a sickle cell crisis. Although children with sickle cell disease are at increased risk for infections, which can cause fever, a fever is not a typical finding specifically related to a sickle cell crisis. It is essential to assess for infection, especially if fever is present.
D. Pain is the hallmark symptom of a sickle cell crisis, often referred to as a vaso-occlusive crisis. The sickle-shaped red blood cells can block blood flow in small vessels, leading to severe pain in various parts of the body, such as the chest, abdomen, and joints.

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A nurse is preparing to administer morphine 4 mg IV bolus to a client who reports pain. Available is morphine 10 mg/mL. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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