When documenting notification of the primary health care provider concerning a client whose condition is deteriorating, the nurse must be sure to include which of the following? (Select all that apply.)
1. Client's wife at bedside.
2. Client rating pain at 3 out of 10 at 0920.
3. Client asking to have wife called to come to hospital.
4. Dr. Smith notified of client's pain rating of 8 out of 10 at 0900.
5. Client administered 2 mg morphine sulfate IV every 5 minutes for two doses.
6. Client ordered morphine sulfate 2 mg IV every 5 minutes until pain relief is achieved.
ANS: 2, 4, 5, 6
The nurse must be certain to document that the physician was notified and his or her response, nursing action in follow-up of orders, and the client's response. The remaining options are not relevant to the proper documentation of the situation.
You might also like to view...
Reduction division is called ____________________
Fill in the blank(s) with correct word
The PICO question reads, "Is TENS effective in the management of chronic low-back pain in adults?" Which part of this question comes from the "I" in PICO?
1) Adults 2) Management 3) Pain 4) TENS
An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which collaborative problem should the nurse identify as a priority for this patient?
a. Potential complication: hypovolemic shock b. Potential complication: venous thromboembolism c. Potential complication: fluid and electrolyte imbalance d. Potential complication: impaired surgical wound healing
A patient who is taking digoxin is admitted to the hospital for treatment of congestive heart failure
The prescriber has ordered furosemide (Lasix). The nurse notes an irregular heart rate of 86 beats per minute, a respiratory rate of 22 breaths per minute, and a blood pressure of 130/82 mm Hg. The nurse auscultates crackles in both lungs. Which laboratory value causes the nurse the most concern? a. Blood glucose level of 120 mg/dL b. Oxygen saturation of 90% c. Potassium level of 3.5 mEq/L d. Sodium level of 140 mEq/L