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 .
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Changing the ostomy pouch daily is not necessary and can lead to skin irritation. The pouch should be changed every 2-4 days or as directed by the healthcare provider.
Choice B rationale
The ostomy pouch should be emptied when it is 1/3 to 1/2 full to prevent leakage and skin irritation.
Choice C rationale
Trimming the opening of the ostomy seal to be 1/2 in. wider than the stoma is incorrect. The opening should be just slightly larger than the stoma to prevent skin irritation.
Choice D rationale
Applying lotion to the peristomal skin when changing the ostomy pouch is not recommended as it can interfere with the adhesion of the pouch.
Correct Answer is ["15"]
Explanation
Step 1 is to determine the amount of clindamycin palmitate in each mL of the oral suspension. This is done by dividing the total amount of clindamycin palmitate in 5 mL by 5. So, 75 mg ÷ 5 mL = 15 mg/mL.
Step 2 is to calculate the volume of oral suspension needed to deliver 225 mg of clindamycin palmitate. This is done by dividing the desired dose by the amount of clindamycin palmitate per mL. So, 225 mg ÷ 15 mg/mL = 15 mL.
Therefore, the nurse should administer 15 mL of clindamycin palmitate oral suspension.
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