A client with lung cancer was given an oral narcotic for pain one hour ago. Which finding should the practical nurse (PN) report to the charge nurse?
Heart rate reduced to 100 beats/minute.
Bilateral pupils equal and reactive to light.
Pain decreased to a 2 on a 0 to 10 point pain scale.
Respiratory rate of 6 breaths/minute.
The Correct Answer is D
A. Heart rate reduced to 100 beats/minute:
A HR of 100 is within normal limits for an adult and not concerning here.
B. Bilateral pupils equal and reactive to light:
Normal finding, no immediate concern.
C. Pain decreased to a 2 on a 0 to 10 point pain scale:
Indicates the medication was effective for pain relief.
D. Respiratory rate of 6 breaths/minute:
Dangerously low; indicates opioid-induced respiratory depression requiring immediate action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Wear clean gloves during auscultation of a client's heart sounds, lung sounds, and bowel sounds. Gloves not required for auscultation unless contact with body fluids is anticipated.
B. Dispose of gastric residual volume obtained when aspirating a client's nasogastric tube: Standard practice unless facility policy specifies reinsertion; prevents aspiration risk.
C. Weigh mother holding infant then subtract the mother's weight to obtain the infant's weight: Not part of a focused assessment but a measurement technique.
D. Place BP cuff on thigh of a client with burns to the upper extremities: Adaptation for burn injuries but not related to general focused assessment steps.
Correct Answer is ["B","C","E"]
No explanation
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