A nurse is assisting a postoperative client.

The client is alert and oriented to person, place, and time, and reports incisional pain of 9 on a scale of 1 to 10. Morphine 8 mg was administered subcutaneously as prescribed at 0900.

The client is now sleeping and is difficult to arouse.

Pupils are 3 mm, equal and reactive to light.

Temperature is 37.5 C (99.5°), respirations are 10/min, and pulse oximetry is 87% on room air.

Which documentation in the client’s medical record requires further action by the nurse?

Pupils are 3 mm, equal and reactive to light

Client is sleeping and is difficult to arouse

Respirations are 10/min

Pulse oximetry is 87% on room air .

Answer and Explanation

The Correct Answer is D

Choice A rationale
Pupils being 3 mm, equal and reactive to light is a normal finding and does not require further action.
Choice B rationale
The client being difficult to arouse could be a side effect of the morphine. However, this is not as immediately concerning as a low oxygen saturation.
Choice C rationale
Respirations being 10/min could be a side effect of the morphine. However, this is not as immediately concerning as a low oxygen saturation.
Choice D rationale
Pulse oximetry reading of 87% on room air is concerning. Normal pulse oximetry readings are typically between 95% and 100%. A reading of 87% indicates the client is not getting enough oxygen, which requires immediate action.

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Correct Answer is D

Explanation

Choice A rationale
Taking two tablets every 15 minutes is not the recommended dosing for nitroglycerin. Overdosing can lead to hypotension and other side effects.
Choice B rationale
While the client should take the nitroglycerin sublingually, taking one tablet every 15 minutes up to 5 times is not the recommended dosing. This could lead to an overdose.
Choice C rationale
Nitroglycerin should be taken sublingually, not orally, for rapid absorption. Taking one tablet orally every hour up to 5 times is not the recommended dosing.
Choice D rationale
This is the correct dosing for nitroglycerin. If chest pain persists after the third dose, the client should seek immediate medical attention.

A. At the time the client takes a proton-pump inhibitor. B. At the time the client takes an antacid. C. One hour before breakfast and the evening meal. D. Thirty minutes after breakfast and the evening meal.

Correct Answer is C

Explanation

Choice A rationale
At the time the client takes a proton-pump inhibitor. Sucralfate and proton pump inhibitors should not be taken at the same time. Sucralfate can interfere with the absorption of other medications.
Choice B rationale
At the time the client takes an antacid. Sucralfate and antacids should not be taken at the same time. Sucralfate can interfere with the absorption of other medications.
Choice C rationale
One hour before breakfast and the evening meal. This is the correct answer. Sucralfate is most effective when taken on an empty stomach. Taking it one hour before meals allows it to form a protective coating on the ulcer before food is introduced into the stomach.
Choice D rationale
Thirty minutes after breakfast and the evening meal. Sucralfate should not be taken immediately after meals. It is most effective when taken on an empty stomach.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is instructing the client on the correct way to take nitroglycerin as needed for chest pain. Which is the correct instruction?

Correct Answer is D

Explanation

A nurse is planning care for a client who has a peptic ulcer and a new prescription for sucralfate 2 gm administered twice daily. When should the nurse plan to administer the medication?

Correct Answer is C

Explanation

A nurse is contributing to the plan of care for a client who has urolithiasis. Which of the following interventions should the nurse include in the plan?

A nurse is attending to a client experiencing hypovolemic shock. What findings should the nurse anticipate?

A nurse is assisting in the care of a client who has developed cardiogenic shock. Which pulse site should the nurse use when assessing circulation to the client’s brain?

A nurse is collecting data from a client who has peptic ulcer disease. Which of the following findings is a manifestation of gastrointestinal perforation?

A patient with acute pancreatitis is in severe pain. Which position should the nurse suggest the patient to assume?

A patient with a colostomy says, “My pouch blows up like a balloon when I pass gas.”. What is an appropriate response by the nurse?

A patient is unresponsive to verbal stimuli and exhibits an altered level of consciousness. Which method should the nurse use to elicit a response from a painful stimulus?

A client with a terminal illness asks the nurse, “If I have a DNR prescription, does that mean I will no longer receive any treatment for my condition?” Which of the following statements should the nurse provide to explain a DNR prescription?