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Zorluk: OrtaPharmacological Therapies

An adult client who recently underwent orthopedic surgery is receiving care on a medical-surgical unit. The client reports a pain level of 8 on a 0-to-10 scale and requests their prescribed as-needed (PRN) oral oxycodone. During the pre-administration assessment, the practical nurse (PN) notes that the client is extremely drowsy and has a respiratory rate of 9 breaths per minute. Which of the following actions should the PN take?

  1. Withhold the oxycodone and immediately report the client's respiratory status to the registered nurse.Cevap
  2. B
    Administer the prescribed oral oxycodone to promptly address the client's severe pain.
  3. C
    Verify the client's name and date of birth before proceeding with the medication administration.
  4. D
    Independently administer intravenous naloxone to reverse the client's respiratory depression.

Cevap

The PN must withhold the oxycodone and immediately report the client's respiratory status to the registered nurse.
The correct action is to withhold the oxycodone and report the findings to the registered nurse. Oxycodone is an opioid analgesic that causes central nervous system depression. A respiratory rate of 9 breaths per minute indicates respiratory depression (normal is 12-20 breaths per minute). The PN must prioritize airway and breathing (ABC framework) over pain management, safely withhold the contraindicated medication, and escalate the critical finding to the RN.

Adım Adım Çözüm

1
Assess the client's pre-administration vital signs and level of consciousness.
The respiratory rate is 9 breaths per minute, which indicates significant bradypnea and respiratory depression.
Opioid analgesics like oxycodone depress the central nervous system, and a safe respiratory baseline (typically 12 or more breaths per minute) is required before administration.
2
Evaluate findings against the ABC (Airway, Breathing, Circulation) prioritization framework.
Breathing is compromised, making it a higher priority than the client's severe pain.
Airway and breathing must always take precedence over pain management in emergent or unstable clinical scenarios.
3
Determine the appropriate action based on the practical nurse (PN) scope of practice.
The medication is withheld and the abnormal finding is escalated to the supervising registered nurse (RN).
The PN must safeguard the client by withholding contraindicated medications and reporting critical deviations to the RN for further medical evaluation.

Anahtar Kavram

Opioid administration safety, ABC prioritization, and the practical nurse scope of practice regarding critical assessment findings.
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Pharmacological Therapies

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