RN HESI Pharmacology Exam
RN HESI Pharmacology Exam ( 31 Questions)
Patient Data
History and Physical
The client is a 42-year-old female who had a right above-the-knee amputation for osteomyelitis. The client has a drain in place and a surgical dressing that will need to be changed by the surgeon on post-op day 1.
Nurses Notes
1400: Started continuous morphine in the left antecubital vein peripheral intravenous line. No redness, edema, or bleeding noted at the site. Vital signs: heart rate 77 bpm, blood pressure 118/74 mmHg, respiratory rate 16.
1800: Vital signs: heart rate 79 bpm, blood pressure 114/78 mmHg, respiratory rate 14.
1900: Responded to an alarm in the room. The client is not responsive. Her respiratory rate is 5 bpm. Her heart rate is 92 bpm. Her pupils are pinpoint.
Orders:
- Admit to the surgical floor
- Clear liquid diet, advance as tolerated
- Continuous cardiorespiratory monitoring
- Morphine 1 mg/hr intravenously
- Alert surgeon to signs of bleeding or infection in the surgical site
- Docusate sodium 240 mg orally every am
- Naloxone 2 mg intravenously as needed for respiratory depression
- Ibuprofen 600 mg orally every 6 hours
What should the nurse do immediately? Select all that apply.
Choice A: Printing an electrocardiogram strip is not a priority in this situation. The client is not responsive and has a low respiratory rate, which indicates a possible overdose of morphine. The nurse should focus on reversing the effects of the opioid and maintaining the client's airway and circulation.
Choice B: Providing rescue breaths with a manual ventilation bag is a correct and urgent action. It can supply oxygen to the client until naloxone takes effect and restore normal breathing.
Choice C: Giving naloxone 2 mg intravenously is a correct and urgent action. Naloxone is an opioid antagonist that can block the effects of morphine and reverse respiratory depression.
Choice D: This can help increase the patient’s oxygen levels, which may be low due to the decreased respiratory rate.
Choice E: Performing chest compressions is not a correct or urgent action. It is only indicated if the client has no pulse or signs of life. It can also cause harm if the client has a heartbeat.
Choice F: Calling for rapid response is a correct and urgent action. Rapid response is a team of health care professionals that can assist in emergency situations and provide advanced care.
Choice A: Printing an electrocardiogram strip is not a priority in this situation. The client is not responsive and has a low respiratory rate, which indicates a possible overdose of morphine. The nurse should focus on reversing the effects of the opioid and maintaining the client's airway and circulation.
Choice B: Providing rescue breaths with a manual ventilation bag is a correct and urgent action. It can supply oxygen to the client until naloxone takes effect and restore normal breathing.
Choice C: Giving naloxone 2 mg intravenously is a correct and urgent action. Naloxone is an opioid antagonist that can block the effects of morphine and reverse respiratory depression.
Choice D: This can help increase the patient’s oxygen levels, which may be low due to the decreased respiratory rate.
Choice E: Performing chest compressions is not a correct or urgent action. It is only indicated if the client has no pulse or signs of life. It can also cause harm if the client has a heartbeat.
Choice F: Calling for rapid response is a correct and urgent action. Rapid response is a team of health care professionals that can assist in emergency situations and provide advanced care.