Question 1
A patient scores positive on the Confusion Assessment Method of the Intensive Care Unit (CAM-ICU). Which nursing diagnosis would have the highest priority based on this positive score?
◦ Memory Impaired
◦ Injury, Risk for
◦ Social Interaction, Impaired
◦ Family Processes, Altered
Question 2
Which nursing action would be appropriate when the nurse initiates an infusion of morphine sulfate for a post-operative patient who is experiencing pain?
◦ Anticipate that the patient will begin to experience the effect of the morphine 15 minutes after the start of the infusion.
◦ Provide additional intermittent boluses of morphine sulfate if the patient experiences breakthrough pain.
◦ Begin the infusion at the lowest ordered dose, and increase the rate every 30 minutes if the patient continues to have pain.
◦ Complete the Critical-Care Pain Observation Tool scale 5 minutes after increasing the infusion rate each time.
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