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.

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Correct Answer is D

Explanation

A. Minimize the amount of fluid taken while on this drug: Increasing fluid intake is actually recommended to manage potential constipation, another common side effect of anticholinergic medications.
B. Discontinue the medication if adverse effects occur: Discontinuing medication without consulting a healthcare provider is not advisable. Patients should be educated to report any adverse effects to their healthcare provider for appropriate management.
C. Take the medication on an empty stomach to enhance absorption: Benztropine is typically taken with food to minimize gastrointestinal side effects. Taking it on an empty stomach may increase the risk of nausea or stomach upset.
D. Use artificial saliva, sugarless gum, or hard candy to counteract dry mouth: Anticholinergic medications such as benztropine commonly cause dry mouth as a side effect. Stimulating saliva production with these measures can help alleviate dry mouth symptoms.

A. Do slow position changes to avoid falls from lowering blood pressure." B. if you feel short of breath, use a rescue inhaler. C. "If possible, try to avoid rooms that are cold." D. "Make sure to seek care immediately if you're not able to urinate."

Correct Answer is D

Explanation

A. Do slow position changes to avoid falls from lowering blood pressure: This is not the priority teaching point for an anticholinergic medication. While some anticholinergics can cause orthostatic hypotension, the risk of urinary retention is a more significant concern.
B. If you feel short of breath, use a rescue inhaler: This instruction is unrelated to the use of anticholinergic medication and may be more relevant for patients with emphysema.
C. "If possible, try to avoid rooms that are cold.": Avoiding cold rooms is not directly related to the use of anticholinergic medication. The priority teaching point should address potential adverse effects specific to the medication.
D. "Make sure to seek care immediately if you're not able to urinate.": Anticholinergic medications can exacerbate urinary retention, particularly in older adults with benign prostatic hyperplasia. It's crucial for the patient to understand the importance of seeking medical attention if they experience difficulty urinating.

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Naxlex Comprehensive Predictor Exams

When a patient is taking an anticholinergic such as benztropine as part of the treatment for Parkinson's disease, the nurse should include which information in the teaching plan?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

A nurse is providing teaching to a client who has a new diagnosis of Parkinson's disease. On which of the following medications should the nurse prepare to instruct the client?

A nurse is preparing to administer amantadine 150 mg PO every 12 hr. Available is amantadine 50 mg/5 mL syrup. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

The nurse is reviewing the use of central nervous system stimulants. Which of these are indications for this class of drugs? (Select all that apply.)

The nurse has given medication instructions to a patient receiving phenytoin. Which statement by the patient indicates that the patient has an adequate understanding of the instructions?

A patient has been treated with antiparkinson medications for 3 months. What therapeutic responses should the nurse look for when assessing this patient?

When evaluating a patient who is taking orlistat, which is an intended therapeutic effect?

A patient had abdominal surgery this morning. The patient is groggy but complaining of severe pain around the incision. What is the most important assessment data to consider before the nurse administers a dose of morphine sulfate to the patient?