correct answers
Highlight the findings that are of immediate concern.
Mr. Carson is a 68-year-old client of Rd. Richards and was admitted to the intensive
care unit at Cornerstone Care Centre for metastatic bone cancer and acute renal
failure. Mr. Carson's heart and kidneys were failing, but full code status is in place.
Mr. Carson had peritoneal dialysis this morning and was awake, but nonverbal.
Mr. Carson's family member was at the bedside and alerted the registered nurse that
their dad was moaning and restless in bed. They were concerned about their dad's
pain level. Mr. Carson was able to point to the FACES pain scale and rated current
pain level an 8 out of 10. Vital signs: T 100ºF (38ºC), P 138, R 32 on non-rebreather
mask. - ANSWERS -moaning and restless in bed
-pain level an 8 out of 10
-T 100F (38C), P 138, R 32
-Fentanyl 1000 mcg sublingual tab
-override the medication dispensing system
-administered the medication
The client is at risk for _________ due to _______ dose of medication. - ANSWERS
CNS depression
high
The nurse should have utilized the _________, followed by questioning the
medication ________. - ANSWERS rights to medication administration
dose
Identify which interventions are indicated or contraindicated for the care of Mr.
Carson.
Review the rights of medication administration prior to medication administration.
Monitor type, location, and intensity of pain before and 1 hour after administration.
Assess BP, pulse, and respirations before and periodically during administration. If
respiratory rate is <10 min, assess the level of sedation.
Notify the prescribing provider of the high fentanyl dosage.
Override a medication dispensing system (MDS) to obtain a prescribed nonemergent
medication.
Notify the charge nurse immediately to complete an incident report. - ANSWERS
Indicated -->
-Review the rights of medication administration prior to medication administration.
-Monitor type, location, and intensity of pain before and 1 hour after administration.
-Assess BP, pulse, and respirations before and periodically during administration. If
respiratory rate is <10 min, assess the level of sedation.
-Notify the prescribing provider of the high fentanyl dosage.
-Notify the charge nurse immediately to complete an incident report.
Contraindicated-->