The MedSurg nurse assesses a patient after arriving on the unit from the PACU. The patient states that she is in pain, rating the pain at a 7 out of 10. The nurse administers 4mg morphine IV as prescribed. After administering the drug, the PACU nurse calls to say a dose of morphine was given and not documented. What actions should the nurse perform? (Select all that apply) (Select All that Apply.)

Monitor the patient's respiratory rate

Ensure naloxone is readily available

Report the error to the facility through the proper paperwork

Inform the patient's health care provider

Document the dose of morphine given by the MedSurg nurse

Answer and Explanation

Correct Answer : A,C,D,E

A.   Monitor the patient's respiratory rate: It's essential to monitor the patient for any adverse effects of morphine administration, particularly respiratory depression.
B.   Ensure naloxone is readily available: While naloxone is an antidote for opioid overdose, administering it would depend on the patient's response and any signs of opioid toxicity, which may not be evident at this time.
C.   Report the error to the facility through the proper paperwork: Reporting the medication error is crucial for documentation, investigation, and implementation of corrective actions.
D.   Inform the patient's health care provider: The healthcare provider should be notified of the medication error to ensure appropriate follow-up and monitoring of the patient.
E.   Document the dose of morphine given by the MedSurg nurse: Documenting the medication administration accurately is essential for the patient's medical record and continuity of care.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Take the medication in the morning to prevent insomnia: This instruction is not directly

related to minimizing anticholinergic effects; it's more about managing the timing of medication administration.
B. Use cooling measures to decrease fever: Anticholinergic effects do not typically cause fever, so this instruction is not relevant.
C. Chew sugarless gum to moisten the mouth: Anticholinergic medications can cause dry mouth (xerostomia), and chewing gum can stimulate saliva production, alleviating this side effect.
D. Take an antacid to relieve nausea: Anticholinergic effects can include nausea, but taking an antacid is not a specific strategy for managing this side effect.

A. Menstrual cramps B. Constipation C. Muscle aches D. Incision pain after surgery

Correct Answer is A

Explanation

A. Menstrual cramps: Feverfew is commonly used as an herbal remedy for menstrual cramps and migraines due to its purported anti-inflammatory and smooth muscle relaxant properties.
B. Constipation: Feverfew is not typically used to treat constipation.

C. Muscle aches: While feverfew may have some anti-inflammatory properties, it is not commonly used specifically for muscle aches.
D. Incision pain after surgery: Feverfew is not typically used to manage post-surgical pain.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a patient who has schizophrenia strategies to cope with anticholinergic effects of fluphenazine. Which of the following should the nurse suggest to the patient to minimize anticholinergic effects?

Correct Answer is C

Explanation

The nurse is reviewing herbal therapies. Which is a common use of the herb feverfew?

Correct Answer is A

Explanation

The barbiturate phenobarbital is prescribed for a patient with epilepsy. While assessing the patient's current medications, the nurse recognizes that interactions may occur with which drugs? (Select all that apply.)

The U.S. Food and Drug Administration has issued a warning for users of antiepileptic drugs. Based on this report, the nurse will monitor for which potential problems with this class of drugs?

The nurse is assessing a patient for contraindications to drug therapy with acetaminophen. Which patient should not receive acetaminophen?

A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching?

When assessing patients in the preoperative area, the nurse knows that which patient is at a higher risk for an altered response to anesthesia

A nurse is caring for a client who has schizophrenia and is taking haloperidol. The nurse should monitor for which of the following adverse effects of haloperidol?