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
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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Related Questions
Correct Answer is D
Explanation
A. Assessment of the patient's pain level: While pain assessment is important, the patient's lethargy and shallow respirations indicate a potential opioid overdose, which takes priority.
B. Close observation of signs of opioid tolerance: The patient's symptoms are indicative of opioid overdose, not tolerance.
C. Immediate intubation and artificial ventilation: While respiratory support may eventually be necessary if the patient's condition deteriorates further, administering naloxone to reverse the opioid effects is the initial priority.
D. Administration of naloxone: Naloxone is an opioid antagonist used to reverse opioid overdose by blocking opioid receptors, which can rapidly restore normal respiratory function and
consciousness in patients experiencing opioid-induced respiratory depression.
Correct Answer is B
Explanation
A. Bupropion is primarily used as an antidepressant and smoking cessation aid. It is not typically used for opioid withdrawal.
B. Methadone is a synthetic opioid agonist commonly used in the management of opioid withdrawal. It helps to alleviate withdrawal symptoms and can be used as part of a long-term maintenance program for opioid dependence.
C. Disulfiram is used in the treatment of alcohol dependence by creating unpleasant effects when alcohol is consumed. It is not indicated for opioid withdrawal.
D. Phenobarbital is a barbiturate with sedative and anticonvulsant properties. While it can be used to manage certain withdrawal symptoms, such as seizures associated with alcohol withdrawal, it is not typically used as a first-line treatment for opioid withdrawal.
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