Give or Hold?
COPD patient is wheezing. Albuterol is ordered. HR 88.
Give.
Albuterol is appropriate for bronchospasm, and the heart rate is not severely elevated.
CHF patient is receiving Lasix.
Potassium.
Lasix can lower potassium, which increases dysrhythmia risk.
Potassium is 2.8.
Dysrhythmias.
Low potassium can cause dangerous cardiac rhythm changes.
Lasix is held because K+ is 2.8. What should you monitor?
Potassium, telemetry, lung sounds, edema, daily weight, and I&O.
Monitor potassium/telemetry for improvement and dysrhythmias; monitor fluid status because CHF may worsen while Lasix is held
Which patient should be seen first: pain 8/10 or RR 8?
RR 8.
Airway and breathing are higher priority than pain.
Pneumonia patient has WBC 15 and ceftriaxone ordered. No allergy is listed.
Give.
Ceftriaxone treats bacterial infection, and elevated WBC supports the need for antibiotic therapy.
Patient is receiving Warfarin.
INR.
INR measures anticoagulation effect and bleeding risk for warfarin.
INR is 5.5.
Bleeding.
A high INR means blood is taking too long to clot.
Metoprolol is held because HR is 48. What should you monitor?
HR, BP, dizziness, chest pain, and perfusion.
You are looking for HR to improve while ensuring the patient does not develop poor perfusion or cardiac symptoms.
Which patient should be seen first: temperature 100.8 or blood glucose 62?
Blood glucose 62.
Hypoglycemia can rapidly affect brain function and requires prompt treatment.
A-Fib patient has metoprolol ordered. HR 48.
Hold.
Metoprolol lowers heart rate and could worsen bradycardia and decrease cardiac output.
Patient is receiving Vancomycin.
Vancomycin trough and creatinine.
Trough monitors toxicity/therapeutic range, and creatinine monitors kidney function.
Creatinine is 3.2.
Kidney injury.
Elevated creatinine indicates impaired kidney function and affects medication clearance.
Insulin is held because BG is 58. What should you monitor?
Repeat blood glucose, level of consciousness, sweating, shakiness, and ability to eat.
You are looking for glucose to rise and hypoglycemia symptoms to resolve.
Which patient should be seen first: potassium 2.8 or BP 182/82?
Potassium 2.8.
Hypokalemia increases risk for dangerous dysrhythmias.
Type 2 diabetes patient has insulin lispro ordered. Blood glucose is 58.
Hold.
Lispro would lower blood glucose further and could worsen hypoglycemia.
Patient is receiving Digoxin.
Digoxin level and potassium
Digoxin toxicity risk increases with abnormal levels and low potassium.
Respiratory rate is 8 after opioid administration.
Respiratory depression
A low respiratory rate may lead to hypoxia and respiratory failure
Vancomycin is held because the trough is toxic. What should you monitor?
Creatinine, BUN, urine output, trough level, WBC, and temperature.
You are looking for kidney function and trough to improve while ensuring infection does not worsen.
Which patient should be seen first: active GI bleed or cholesterol 240?
Active GI bleed.
Active bleeding is an immediate safety and perfusion concern.
Patient has morphine ordered for pain. Respiratory rate is 8.
Hold.
Morphine can cause respiratory depression, and RR 8 indicates unsafe respiratory status.
Patient is receiving Metformin.
Creatinine and GFR.
Metformin is cleared by the kidneys; poor renal function increases lactic acidosis risk.
Oxygen saturation is 84%.
Hypoxia.
Low oxygen saturation means tissues may not be receiving enough oxygen for tissue perfusion
Morphine is held because RR is 8. What should you monitor?
RR, oxygen saturation, sedation level, level of consciousness, BP, and pain.
You are looking for respiratory status and alertness to improve while still assessing pain control.
Which patient should be seen first: oxygen saturation 84% or HR 125?
Oxygen saturation 84%.
Hypoxia is an immediate ABC priority.