A nurse is caring for a client.
Exhibits

The nurse reviews the medication administration record following the 0815 assessment findings. Which of the following administered medications would require an incident report?

Propranolol

Pantoprazole

Lovastatin

Morphine

Answer and Explanation

The Correct Answer is A

A. Propranolol is a beta-blocker used to control blood pressure and heart rate. However, the nurse has a hold order for propranolol if the apical pulse (heart rate) is less than 50 beats per minute. The nurse documented a heart rate of 42 bpm at 0815, which falls below the hold parameter for propranolol. Administering propranolol in this case could worsen the client's bradycardia (slow heart rate) and therefore requires an incident report.
B. Pantoprazole is a proton pump inhibitor and doesn't have a direct impact on heart rate within the usual therapeutic range.
C. Lovastatin is a cholesterol medication and wouldn't cause a significant drop in heart rate at this dosage.
D. While morphine can slow the heart rate, it's typically used for pain management and may be necessary for the client's comfort. However, the nurse should monitor the respiratory rate closely due to potential respiratory depression.
E. Cefuroxime is an antibiotic and wouldn't significantly affect heart rate.

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Correct Answer is ["B","D","E"]

Explanation

A. Allergies
Allergies are important to know but are not part of the primary survey. The primary survey focuses on immediate life threats, such as airway, breathing, and circulation, rather than detailed background information.
B. Circulation
Assessment of circulation is critical in the primary survey to identify and manage life-threatening conditions such as shock or severe bleeding. It includes evaluating blood pressure, heart rate, and peripheral pulses to assess the effectiveness of the cardiovascular system.
C. Neurological status
While neurological status is important, it is part of a secondary survey rather than the primary survey. The primary survey focuses on immediate life-threatening conditions, while the neurological status is assessed more thoroughly in the secondary survey.
D. Ventilation
Assessing ventilation is a crucial part of the primary survey. This involves checking the client's breathing rate, depth, and effectiveness to ensure adequate oxygenation and addressing any immediate respiratory distress.
E. Current medications
Knowing current medications is important for overall care but is not part of the primary survey. The primary survey addresses life-threatening conditions rather than details of medication history.
F. Exposure
Exposure is part of the primary survey, ensuring that the client is completely exposed for a thorough assessment while protecting their privacy and warmth. It involves checking for hidden injuries and ensuring the client’s environment is safe.

A. A client who is being discharged to a long-term care facility B. A client who is postoperative following a lobectomy and has a chest tube C. A client who needs teaching about insulin self-administration D. A client who needs teaching prior to initiating cardiac rehabilitation activities

Correct Answer is B

Explanation

A. A client being discharged to a long-term care facility may need comprehensive discharge planning, which involves familiarity with long-term care requirements, but this is not typically within the primary expertise of a PACU nurse.
B. A client who is postoperative following a lobectomy and has a chest tube falls within the PACU nurse's area of expertise. PACU nurses are experienced in monitoring and managing postoperative clients, including those with chest tubes, as these clients require close monitoring for complications such as respiratory distress or chest tube malfunction.
C. Teaching about insulin self-administration is important, but this task is more suited to nurses experienced in chronic care management, such as those from medical-surgical or endocrinology units.
D. Teaching prior to initiating cardiac rehabilitation requires specialized knowledge in cardiac care, which may not be the primary focus of a PACU nurse's practice.

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A nurse is caring for a client. Exhibits The nurse reviews the medication administration record following the 0815 assessment findings. Which of the following administered medications would require an incident report?

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A nurse is caring for a client.
Exhibits

The nurse reviews the medication administration record following the 0815 assessment findings. Which of the following administered medications would require an incident report?