# A nurse receives a postoperative order to give 1 mg hydromorphone IV every 4 hours PRN for severe pain. The pharmacy delivered prefilled syringes labeled hydromorphone 4 mg/mL. Which is the priority nursing action before administration?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375157&lang=en  
> language: en  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PA

## Question

A nurse receives a postoperative order to give 1 mg hydromorphone IV every 4 hours PRN for severe pain. The pharmacy delivered prefilled syringes labeled hydromorphone 4 mg/mL. Which is the priority nursing action before administration?

## Option

1. Convert the dose using an equianalgesic table, determine that 1 mg hydromorphone is equivalent to 7 mg morphine, obtain that morphine dose from stock, and administer it instead of hydromorphone to avoid manipulating the high-concentration prefilled syringe.
2. Discard the entire prefilled syringe as pharmaceutical waste, notify the pharmacy that the available concentration is unsafe for the ordered dose, and wait for a replacement syringe with a lower concentration such as 1 mg/mL to prevent a potential medication error.
3. Administer the full 1 mL volume from the prefilled syringe because the order is for 1 mg and the syringe is labeled as 1 mL, so the entire contents match the ordered dose when the concentration is 1 mg/mL, which is a standard concentration for hydromorphone.
4. Recognize the high-alert mismatch, do not give the syringe as drawn, draw 0.25 mL (1 mg) from the prefilled syringe with a separate syringe and waste 0.75 mL with a witness, double-check the dose with another nurse, and document the wasted volume. **✔ Correct answer**

**Correct answer: 4**

## Explanation

Hydromorphone (Dilaudid) is approximately 7 times more potent than morphine when given IV (1 mg IV hydromorphone is roughly equivalent to 7 mg IV morphine). It is on every high-alert medication list because dose-confusion errors with morphine are common and frequently fatal. Standard ISMP and Joint Commission safe practices: (1) verify the order, the indication, the patient, and check for opioid tolerance; (2) recognize that a 4 mg/mL syringe contains four full doses for a 1 mg order — never give the entire prefilled syringe; (3) draw the prescribed 0.25 mL (1 mg) into a separate syringe and waste the remainder with a licensed witness, document the waste; (4) two-nurse independent double check before administration is recommended for high-alert IV opioids in many institutions; (5) administer slowly over 2 to 3 minutes IV; (6) reassess pain, sedation level (POSS), respiratory rate, and SpO2 before, during, and after; (7) renarcotization is unlikely with a single 1 mg dose, but cumulative dosing requires monitoring. Discarding the syringe and calling pharmacy delays needed analgesia. Substituting morphine without an order is unsafe. Giving the full 4 mg is a fatal error.

## In-depth explanation

High-alert recognition + waste with witness + double check is the safe path. Hydromorphone is not morphine — never assume equivalence and never give a prefilled syringe at face value.

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