A patient is taking meperidine (Demerol) as needed for moderate to severe pain following an open appendectomy
The nurse assesses the following: current pain level 2, temperature 99° F, BP 130/76, respirations 10, lung sounds clear, abdomen soft and tender, bowel sounds present. Based on this assessment information, the priority nursing diagnosis is
a. altered breathing pattern.
b. risk for altered body temperature.
c. risk for constipation.
d. pain.
ANS: A
Meperidine (Demerol) is an opiate agonist and can cause respiratory depression. Respirations less than 12/min indicate altered breathing pattern and require immediate intervention. Temperature of 99° F is not the priority concern. The abdomen is soft, so there is no indication of constipation. Pain level of 2 is considered mild; therefore, this is not the top priority.
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