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Zorluk: OrtaPharmacological Therapies

A practical nurse is caring for a client receiving oral morphine sulfate for cancer-related pain. The client's spouse states, "My partner is in a lot of pain, please give the next dose of medication." Upon assessment, the nurse observes that the client is somnolent, difficult to arouse, and has a respiratory rate of 10 breaths per minute10\text{ breaths per minute}. Which action should the nurse take first?

  1. A
    Provide the prescribed oral morphine to manage the pain as requested by the spouse.
  2. Withhold the scheduled medication and immediately notify the registered nurse of the client's respiratory status.Cevap
  3. C
    Prepare to independently administer intravenous naloxone to reverse the suspected opioid toxicity.
  4. D
    Give the medication quickly to relieve the pain, bypassing the barcode scanning process due to the urgency.

Cevap

The practical nurse should withhold the scheduled medication and immediately notify the registered nurse of the client's respiratory status.
The correct action is to withhold the medication and notify the registered nurse. A respiratory rate of 10 breaths per minute10\text{ breaths per minute} and somnolence are classic signs of opioid toxicity. Giving further doses of morphine could lead to fatal respiratory arrest. The practical nurse is acting safely and within their scope of practice by holding the medication and reporting the critical findings up the chain of command.

Adım Adım Çözüm

1
Assess the client's vital signs and level of consciousness prior to opioid administration.
The client is somnolent with a respiratory rate of 10 breaths per minute10\text{ breaths per minute}.
Opioids like morphine can cause life-threatening central nervous system and respiratory depression.
2
Prioritize the assessment findings using the Airway, Breathing, Circulation (ABC) framework.
The compromised respiratory rate and somnolence take priority over the spouse's request for pain management.
A respiratory rate below 12 breaths per minute12\text{ breaths per minute} is a critical sign of respiratory depression.
3
Determine the appropriate intervention within the practical nurse scope of practice.
The nurse withholds the dose and escalates the critical findings to the registered nurse.
The practical nurse must protect the client from further harm and report abnormal findings to the supervising nurse for advanced intervention.

Anahtar Kavram

Opioid-induced respiratory depression and the practical nurse's role in safe medication administration.
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Konular

Pharmacological Therapies

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