A nurse is caring for a client who is receiving continuous IV therapy.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

Based on the client's manifestations, they developed

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and

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Rationale

A. Oral temperature 37.4° C (99.3° F): This temperature is within normal limits and does not indicate a concerning postoperative complication. Mild elevations can occur due to surgery or mild inflammatory responses, but this finding alone does not require provider notification.

B. BP 130/84 mm Hg: This blood pressure reading is slightly elevated but generally within acceptable postoperative limits. It does not indicate immediate risk from opioid therapy and does not necessitate urgent reporting.

C. Heart rate 88/min: A heart rate in the high-normal range is not unusual postoperatively and is not concerning in the context of opioid administration. Monitoring should continue, but this finding does not require immediate provider notification.

D. Respiratory rate 10/min: A respiratory rate below 12 breaths per minute is considered bradypnea and may indicate opioid-induced respiratory depression. This is a potentially life-threatening complication that requires immediate notification of the provider and prompt intervention to ensure adequate ventilation and oxygenation.

Rationale

A. Access the online drug formulary for an unfamiliar medication: Consulting a reliable drug reference ensures the nurse understands the medication’s indications, dosage, contraindications, side effects, and interactions. This step is essential when administering a medication for the first time to promote safe and informed practice.

B. Use one patient identifier prior to medication administration: Safe medication administration requires two patient identifiers (e.g., name and date of birth) to verify the correct client. Using only one identifier increases the risk of medication errors and does not meet standard safety protocols.

C. Read the medication label twice prior to administration: Best practice is to read the medication label three times, when removing it from storage, before preparing it, and before administering it to ensure accuracy. Reading only twice may allow for errors in drug selection or dosage.

D. Ask the client if they have ever taken a similar medication: While obtaining medication history from the client is useful, it does not replace verification of proper dosage, route, or interactions. Client recollection may be incomplete or inaccurate, so relying on a reference is safer for first-time administration.