nr 341 pharmacology

Age: 32 years

Provider: J. Bellion MD

Allergies: NKDA

Code Status: Full code

Admit Wt: 145 lbs (65.7 kg)

BMI: 24.9

NURSING ASSESSMENT & NOTES

7/9 1930

Cardiac: S1 & S2 present. HR regular and even. No ankle edema. 3+ pedal pulses.

Respiratory: Breathing regular, even, unlabored. Lung sounds clear bilaterally. No cough.

Gastrointestinal: Bowel sounds present and normoactive in all 4 quadrants. Abdomen round, nondistended, non-tender. Last B.M. yesterday, “normal” in appearance.

Genitourinary: Urine yellow and cloudy, foul odor. Stated voids small amounts frequently. + dysuria and frequency.

Skin: Swelling and redness to the right foot. The client is concerned about a spider bite.

Pain: Rates 5/10 flank pain that the client describes as intermittent and sharp.

Lines/Drains: Patent 20 gauge peripheral IV in the right forearm. The dressing is clean, dry, intact. No swelling or redness.

7/9 1930
Nursing Note: Assessment completed. See flowsheets. Client apologetic as children are in the room. “I’m sorry they are so loud. They will leave just as soon as their Abuela gets here. Manuel, do not play with her scanner. She needs that to give mama her medicine.” Ciprofloxacin administered per order.

7/9 1950
Nursing Note: The client notifies the nurse of feeling itchy and having a sensation of airway tightness. “I don’t know what’s happening. I feel funny.” Noted tongue and lip swelling and audible wheezing. Urticaria noted on client’s arm above IV site.

7/9 2002
Nursing Note: The client states, “I don’t feel so good.” The client’s eyes roll back. Client slumps in bed. Not responsive to painful stimuli. No carotid pulse was palpated. Code blue called. Grandmother here as the children were removed from the room and escorted to the waiting room.

7/9 2007
Nursing Note: Return to spontaneous pulse and breathing after epinephrine and defibrillation. Respirations 10, 4L of O2 applied for SpO2 of 95%. Ice packs applied to the groin and axillae. Client prepared for transfer to ICU for close monitoring. Family updated by code team leader.

Question 3

Correct

Mark 33.33 out of 33.33

QUESTION TEXT

Before answering this question, review the client’s health information in the EHR. Listen to the client’s child.

PlayMute

Loaded: 0%

Progress: 0%

-0:12

Determine the nurse’s best actions. Select three (3) that apply.

Call for a social worker to be with the children.

Silence the alarms so that the children are not frightened.

Remove the children from the room.

Tell the children everything will be okay.

Notify the closest relative.

Tell the children they can be in the room if they sit quietly.

Have security come to prevent the children from disrupting the code.

Have the health care provider talk to the children.

FEEDBACK

Your answer is correct.
Debriefing: Great care should be taken when involving the family in the resuscitation process. The children should be removed from the room until they can control enough of their emotions not to disrupt the resuscitation process. Often, a close relative of the client may discern whether the children should see the resuscitation process or not. Having a social worker with the children and providing support is appropriate. The children are currently in escalated distress and should be removed from the situation. Having the health care provider talk to the children is not the best use of resources. It is not appropriate to give false hope or silence alarms.

Consider:

1. What other measures could be taken to support this family during the resuscitation process?

2. How are considerations and explanations tailored to assist children in understanding the dying process in different developmental stages?

3. At what age could a parent’s child be involved in the decision-making process for the dying parent/patient?

The correct answers are:

Remove the children from the room.

Call for a social worker to be with the children.

Notify the closest relative.

QUIZ NAVIGATION

12

VITAL SIGN TREND

Date
Temp °F (°C)
HR
RR
BP
SpO2
O2

7/9 1500
99.6 °F
(37.8 °C)
105
17
122/74
97%
RA

7/9 1900
100.0 °F
(37.8 °C)
103
18
118/78
97%
RA

7/9 1950
deferred
113
24
98/58
87%
RA

PROVIDER PRESCRIPTIONS & NOTES

7/9 1955
Prescriptions: