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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Measure the client’s body temperature: Fever would indicate a systemic infection and helps assess the severity.
B. Observe the appearance of the incision: Important, but systemic assessment for infection should be prioritized first.
C. Assess the degree of skin elasticity: Checks hydration status but is unrelated to assessing wound infection severity.
D. Determine the client’s oxygen saturation: Not the priority unless respiratory distress is suspected.

A. Redness of the cheek under the cannula. B. Dry, cracked mucous membranes. C. Encrustations on both of the eyelids. D. Drooping of the right side of the mouth.

Correct Answer is D

Explanation

A. Redness of the cheek under the cannula: Indicates skin irritation, but can usually be managed locally; not the most urgent.
B. Dry, cracked mucous membranes: Suggests dryness from oxygen but not immediately life-threatening.
C. Encrustations on both of the eyelids: Could indicate infection or poor hygiene but less urgent than neurological changes.
D. Drooping of the right side of the mouth: This could indicate a new-onset stroke (facial droop), which is a neurological emergency requiring immediate reporting.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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