A nurse is caring for four clients receiving pain medication. After the hand-off report, which client should the nurse see first?
a. Client who is crying and agitated
b. Client with a heart rate of 104 beats/min
c. Client with a Pasero Scale score of 4
d. Client with a verbal pain report of 9
ANS: C
The Pasero Opioid-Induced Sedation Scale has scores ranging from S to 1 to 4. A score of 4 indicates unacceptable somnolence and is an emergency. The nurse should see this client first. The nurse can delegate visiting with the crying client to a nursing assistant; the client may be upset and might benefit from talking or a comforting presence. The client whose pain score is 9 needs to be seen next, or the nurse can delegate this assessment to another nurse while working with the priority client. A heart rate of 104 beats/min is slightly above normal, and that client can be seen after the other two clients are cared for.
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