Nursing Prioritization Delegation Assignment Q 28
Two student nurses are assigned to a client with lung cancer who has received oxycodone (Roxicodone) 10 mg orally for pain. During the assessment, which finding should the student nurses report immediately?
A. Decrease in pain level from 6 to 2 (on a scale of 10)
B. Heart rate of 90 to 100 beats/min
C. Request by the client that the room door be closed
D. Respiratory rate of 8 to 10 breaths/min
Correct Answer: D. Respiratory rate of 8 to 10 breaths/min
A drop in respiratory rate indicates respiratory depression, which also puts the client at risk for respiratory acidosis. Signs and symptoms of an oxycodone overdose include bradycardia, hypotension, miosis, respiratory depression, somnolence, muscle flaccidity, cold and clammy skin, and death.
Option A: Oxycodone is an opioid agonist prescription medication. The oxycodone immediate-release formulation is FDA-approved for the management of acute or chronic moderate to severe pain, for which other treatments do not suffice and for which the use of opioid medication is appropriate.
Option B: A heart rate of 100/min is slightly higher than normal, therefore this should still be reported to the RN. Patients taking oxycodone require monitoring for the presence of constipation, pain relief, other side effects, and appropriate usage. Their blood pressure, heart rate, and respiratory rate should also be monitored, especially for the first 24 to 72 hours after initiating therapy or increasing dosage.
Option C: The student nurses should still inform the RN of the client’s wishes. Due to the high misuse potential and possibly fatal results of an oxycodone overdose, prescriptions should be written for the lowest therapeutic dose and only for the period the patient is expected to be in pain. Close follow-up should be arranged.