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hannah20082 hannah20082
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6 years ago
An 80-year-old male patient is in the intensive care unit has suffered a fractured femur. You are making rounds and notice he is somnolent, with no response to verbal or physical stimulation.
 
  He has been on round the clock opioid doses q 4 hours. What is the nurse's first action?
  a. Call the rapid response team to care for the patient immediately.
  b. Discontinue the opioids on the medication administration record.
  c. Assess the patient's blood pressure and pain level.
  d. Start a second intravenous line with a large bore catheter.
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wrote...
6 years ago
ANS: B
After establishing unresponsiveness, the next action is to call a Rapid Response. The patient is not able to subjectively describe pain if unresponsive. Another IV line may be needed, but first the nurse should call for help. The opioids should be discontinued on the MAR; however the priority action is to call for help.
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