27. An older adult patient taking sustained-release morphine 100 mg every 12 hours has become agitated and confused at night. The patient's partner called the physician, and risperidone 1 mg was ordered orally every hour until the patient falls asleep. The patient received 4 doses. The next morning, the partner is unable to arouse the patient and contacts the primary nurse. Which of the following is the MOST appropriate nursing response?
Answer: C
Reviewing the medication orders with the physician is the most appropriate nursing response.
In this situation, it is crucial to address the patient's altered level of consciousness following the administration of risperidone. This requires immediate collaboration with the physician to assess the medication regimen and determine if adjustments are necessary to ensure the patient's safety and well-being.
A) Educate the partner regarding the role of the on-call nurse
While educating the partner about the role of the on-call nurse may be helpful, it does not address the immediate medical concern regarding the patient's decreased responsiveness. The priority should be to evaluate the patient's condition and medication effects rather than focusing on educational information.
B) Obtain an order to reduce the morphine dose
Although reducing the morphine dose may eventually be necessary, this action alone does not address the urgent situation of the patient’s unresponsiveness. The nurse must first consult with the physician regarding the overall treatment plan before making assumptions about dosage adjustments.
C) Review the medication orders with the physician
This is the most appropriate nursing response as it directly addresses the patient's current state. By reviewing the medication orders, the nurse can ensure that the patient's treatment is safe and appropriate, particularly in light of the recent administration of risperidone and the patient's altered mental status.
D) Prepare the partner for the patient's imminent death
Preparing the partner for the patient's imminent death is premature and inappropriate without a thorough assessment of the patient's condition. This response could cause unnecessary distress and does not reflect the immediate need to evaluate the patient's responsiveness and medication effects.
Conclusion
Reviewing the medication orders with the physician is essential to ensure the patient's safety and to determine the appropriate course of action regarding the medications. All other options either fail to address the critical nature of the patient's condition or may lead to unnecessary actions that do not focus on immediate medical needs. Hence, option C is the most responsible and effective response in this scenario.