A nurse is assisting with the care of a client who is postoperative.
Click to highlight the documentation in the client's medical record that require further action by the nurse? To deselect a finding, click on the finding again.
Click to highlight the documentation in the client's medical record that require further action by the nurse? To deselect a finding, click on the finding again.
Temp 37.5°C 99.5 F
Client is difficult to arouse
Respirations 10/min
Pulse oximetry 86% on room air
BP is 96/60 mm Hg
Temp 37.5°C 99.5 F
Client is difficult to arouse
Respirations 10/min
BP is 96/60 mm Hg
Pulse oximetry 86% on room air
The Correct Answer is ["A","B","C","D","E"]
Temp 37.5°C (99.5°F):
This temperature is within normal range and doesn’t require immediate action.
Client is difficult to arouse:
Requires action. This could indicate oversedation or respiratory depression from morphine.
Respirations 10/min:
Requires action. This is on the low side, especially after opioid use. It indicates respiratory depression.
Pulse oximetry 86% on room air:
Requires action. This level is critically low and suggests hypoxia—requires oxygen and immediate follow-up.
BP is 96/60 mm Hg:
Requires action. This is low for a client whose BP was 162/84 an hour earlier, indicating a possible adverse reaction or hemodynamic instability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Rinse the client's mouth before collecting the specimen:
Rinsing helps reduce contamination from saliva and food particles, ensuring a more accurate sputum sample.
B. Obtain the specimen from the client in the evening:
The best time is early morning, when secretions have accumulated overnight.
C. Save the sputum specimen in a clean container:
A sterile container is required for sputum collection to avoid contamination.
D. Collect the sputum specimen after a meal:
Collecting after a meal increases the risk of vomiting or aspiration. Specimen should be collected before meals.
Correct Answer is B
Explanation
A. Decreased heart rate:
Pain typically causes an increased heart rate, not a decrease.
B. Elevated blood pressure:
Pain stimulates the sympathetic nervous system, resulting in increased blood pressure.
C. Reduced respiratory rate:
Pain usually causes an increase in respiratory rate due to stress and anxiety.
D. Constricted pupils:
Pain causes pupil dilation (mydriasis) as part of the fight-or-flight response.
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