A nurse is caring for a client on the medical surgical unit.
Click to highlight the findings at 1630 that require immediate follow-up To deselect a finding, click on the finding again.
|
Body System |
Findings |
|
Cardiovascular |
S1,S2, no murmur, bradycardia |
|
Respiratory |
decreased respiratory effort, equal chest expansion, bilateral crackles |
|
Neurologic |
somnolent |
|
Head, Ears, Eyes, Nose, and Throat (HEENT) |
oropharynx clear, mucous membranes moist pinpoint pupils |
|
Vital Signs |
Temperature 37.4° C (99.4° F) Heart rate 58/min Respiratory rate 10/min Blood pressure 98/58 mm Hg |
S1,S2, no murmur
decreased respiratory effort
bilateral crackles
somnolent
pinpoint pupils
Temperature 37.4° C (99.4° F)
Heart rate 58/min
Respiratory rate 10/min
Blood pressure 98/58 mm Hg
The Correct Answer is ["B","C","D","E","H","I"]
This question focuses on identifying manifestations of opioid-induced respiratory depression following IV morphine administration. Morphine is an opioid analgesic that depresses the central nervous system and can suppress the respiratory drive, especially in postoperative clients who are already sedated from anesthesia. Findings such as somnolence, pinpoint pupils, bradypnea, hypotension, and decreased respiratory effort are classic indicators of opioid toxicity. Early recognition is critical because progressive respiratory depression can rapidly lead to hypoxia, respiratory arrest, and cardiovascular collapse.
Rationale for Correct findings:
• Decreased respiratory effort, bilateral crackles: Decreased respiratory effort following morphine administration is a serious sign of opioid-induced respiratory depression. Opioids suppress the medullary respiratory center, leading to slower and shallower breathing that reduces oxygen exchange. Bilateral crackles may indicate retained secretions, atelectasis, or developing pulmonary complications due to hypoventilation. This finding requires immediate nursing intervention, including respiratory assessment, oxygen support, and possible naloxone administration.
• Somnolent: Excessive somnolence is an early neurologic indicator of opioid oversedation and can precede respiratory arrest. A client who becomes increasingly difficult to arouse may not maintain adequate airway protection or respiratory effort. Monitoring the level of consciousness is essential because declining neurologic responsiveness correlates closely with worsening respiratory depression. Immediate reassessment and provider notification are warranted.
• Pinpoint pupils: Pinpoint pupils, or miosis, are a classic manifestation of opioid effects on the central nervous system. In the postoperative setting, this finding strongly suggests excessive opioid activity, particularly when accompanied by sedation and bradypnea. Although miosis alone may not be dangerous, it becomes clinically significant when occurring alongside respiratory depression. This finding helps confirm suspected opioid toxicity and requires prompt evaluation.
• Respiratory rate 10/min: A respiratory rate of 10/min is abnormally low and indicates bradypnea, which is a major concern after opioid administration. Respiratory depression is one of the most dangerous adverse effects of morphine because inadequate ventilation can lead to carbon dioxide retention and hypoxemia. A declining respiratory rate often precedes respiratory arrest if untreated. Immediate assessment and intervention are necessary to prevent deterioration.
• Blood pressure 98/58 mm Hg: Hypotension can occur with morphine because opioids cause peripheral vasodilation and reduce sympathetic nervous system activity. The client’s blood pressure has dropped significantly from baseline, suggesting a clinically important hemodynamic effect. Combined with sedation and respiratory depression, hypotension may indicate worsening opioid toxicity. Reduced perfusion can compromise oxygen delivery to vital organs and requires urgent monitoring and management.
Rationale for incorrect findings:
• S1, S2, no murmur, bradycardia: A heart rate of 58/min represents mild bradycardia, which can occur postoperatively or secondary to opioid administration. While it should continue to be monitored, it is less immediately dangerous than respiratory depression or altered consciousness. The absence of murmurs or abnormal heart sounds suggests no acute structural cardiac complication.
• Temperature 37.4° C (99.4° F): A temperature of 37.4°C is within a mild postoperative range and does not indicate acute infection or severe systemic complication. Slight elevations in temperature can occur after surgery because of inflammation or stress response. Compared with the client’s respiratory and neurologic changes, this finding is not immediately life-threatening. Ongoing monitoring is appropriate, but urgent intervention is not required based on temperature alone.
• Heart rate 58/min: Although slightly below normal, a heart rate of 58/min is not as critical as the client’s low respiratory rate and decreased responsiveness. Mild bradycardia may occur due to opioid effects, vagal stimulation, or postoperative relaxation. Since perfusion is still being maintained and no dysrhythmias are described, it is a secondary concern at this time. Airway and breathing abnormalities take priority over circulation in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Age-related macular degeneration is a progressive retinal disorder affecting the macula, the portion of the retina responsible for central detailed vision. Degeneration of macular photoreceptor cells leads to impaired visual acuity, difficulty reading, and reduced ability to recognize faces or perform fine visual tasks. Peripheral vision is typically preserved, but central vision progressively deteriorates. Nurses caring for clients with this condition should recognize characteristic visual changes associated with retinal damage.
Rationale:
A. Nystagmus is an involuntary rhythmic eye movement commonly associated with neurologic disorders, vestibular dysfunction, or congenital visual impairment. It is not a characteristic finding of macular degeneration because the disorder primarily affects retinal central vision rather than ocular motor control. Therefore, this finding would not be expected.
B. Astigmatism is a refractive error caused by irregular curvature of the cornea or lens, leading to blurred vision at multiple distances. It is unrelated to retinal degeneration and does not result from macular damage. Macular degeneration affects the retina itself rather than the refractive structures of the eye.
C. Sharp eye pain is not typically associated with macular degeneration. The condition is generally painless because retinal degeneration does not stimulate pain receptors. Sudden or severe ocular pain would suggest another disorder such as glaucoma, corneal injury, or acute inflammation rather than Macular degeneration.
D. Loss of central vision is the hallmark finding of macular degeneration due to progressive deterioration of the macula. Clients commonly report blurred or distorted central vision, difficulty reading, or dark spots in the center of their visual field. Peripheral vision is often maintained despite significant central visual impairment.
Correct Answer is ["A","C","D"]
Explanation
Receiving and transcribing a telephone prescription requires strict adherence to medication safety and communication protocols to prevent errors. A telephone order is considered a high-alert communication process that requires verification steps to ensure accuracy of the prescribed medication, dose, and route. The nurse acts as a critical safety checkpoint by using read-back verification and proper documentation. These measures are essential to reduce medication errors and maintain patient safety.
Rationale:
A. Asking the provider to spell out the name of the medication is essential to prevent misinterpretation of sound-alike or unclear drug names during verbal communication. This reduces the risk of medication errors caused by mishearing or pronunciation differences. It is a standard safety practice during telephone prescriptions.
B. Withholding the medication until the provider signs the prescription is not appropriate because telephone prescriptions are considered valid orders once properly received, read back, and documented. While providers must sign the order within the facility’s policy timeframe, immediate withholding is not required if the order has been correctly verified. Delaying administration could compromise patient care.
C. Requesting that the provider confirm the read-back of the prescription is a critical safety step in medication verification. The nurse repeats the order back to the provider to ensure accuracy, and the provider must confirm correctness. This closed-loop communication reduces transcription and interpretation errors in high-risk verbal orders.
D. Recording the date and time of the telephone prescription is required for legal and clinical documentation purposes. It ensures traceability and accountability of the order and helps maintain an accurate medical record. Proper documentation is essential for continuity of care and regulatory compliance.
E. Having another nurse record the prescription in the medical record is not appropriate because the nurse receiving the order is responsible for documenting it. Delegating transcription to another nurse increases the risk of communication errors and breaks accountability in the medication ordering process. The receiving nurse must ensure accurate documentation and verification.
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