Try Naxlex NCLEX-RN (Free-Trial)

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, bradycardia

decreased respiratory effort

equal chest expansion, bilateral crackles

somnolent

oropharynx clear,

mucous membranes moist

pinpoint pupils

Respiratory rate 10/min

Blood pressure 98/58 mm Hg

Heart rate 58/min

Answer and Explanation

The Correct Answer is ["B","D","G","H","I"]

Decreased respiratory effort, bilateral crackles: Reduced respiratory effort following opioid administration suggests opioid-induced respiratory depression. Crackles may indicate early airway compromise due to poor ventilation or fluid accumulation, requiring immediate intervention to support breathing.
Somnolent: Somnolence beyond expected postoperative drowsiness, especially in combination with other signs of opioid overdose, indicates central nervous system depression. The client is difficult to arouse, raising concern for airway and breathing compromise.
Pinpoint pupils: Pinpoint pupils are a hallmark sign of opioid toxicity. In the setting of recent morphine administration and accompanying respiratory depression, this finding confirms that opioid overdose is likely occurring and must be treated promptly.
Respiratory rate 10/min: A respiratory rate under 12 breaths per minute following opioid administration is a major red flag for opioid-induced respiratory depression. Immediate action is needed to prevent further decline in respiratory status, including potential use of naloxone.
Blood pressure 98/58 mm Hg: The client’s blood pressure has dropped significantly compared to the earlier reading, suggesting opioid-related hypotension. While not yet critically low, the trend combined with other overdose signs indicates instability needing close monitoring and intervention.
Heart rate 58/min: Although the client is bradycardic, this alone is not the most urgent issue compared to respiratory depression and neurological decline. It should still be monitored closely, but it is less immediately life-threatening than the airway and breathing concerns.
Temperature 37.4° C (99.4° F): This temperature is within normal range and does not require follow-up. There are no indications of infection or thermoregulatory issues based on the current temperature.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. "I will use animal skin condoms when having sex.": Animal skin condoms do not provide reliable protection against HIV transmission because they have small pores that can allow viruses to pass through. Latex or synthetic condoms are recommended for effective protection.

B. "I will put soiled dressings in a tied plastic bag before placing them in the trash.": Properly disposing of soiled dressings in a securely tied plastic bag helps prevent the spread of infectious material and minimizes the risk of exposure to others, reflecting good infection control practices at home.

C. "I will place used sharp items in an empty cereal box for disposal.": Sharps should be disposed of in a puncture-resistant, labeled sharps container. An empty cereal box is not puncture-proof and can easily be breached, posing a significant risk for needlestick injuries.

D. "I will disinfect contaminated hard surfaces with a mixture of one part peroxide to 10 parts water.": The correct disinfection solution for HIV is a mixture of one part bleach to 10 parts water, not peroxide. Using an incorrect disinfectant reduces the effectiveness of killing the virus on surfaces.

A. "Your baby is at a higher risk because they were born with congenital dermal melanocytosis.” B. "This is because your baby is breastfed. You should start supplementing with formula." C. "Your baby is at a higher risk because they have had four bowel movements in the first day of life.” D. "This is because your baby's liver is not yet efficient at breaking down red blood cells."

Correct Answer is D

Explanation

A. "Your baby is at a higher risk because they were born with congenital dermal melanocytosis.": Congenital dermal melanocytosis, also known as Mongolian spots, are harmless pigmented birthmarks and are unrelated to bilirubin levels or jaundice risk in newborns.

B. "This is because your baby is breastfed. You should start supplementing with formula.": Breastfeeding itself is not a reason to stop or supplement with formula unless medically necessary. Breastfeeding jaundice can occur, but proper feeding techniques and frequency usually manage it without needing supplementation.

C. "Your baby is at a higher risk because they have had four bowel movements in the first day of life.": Frequent bowel movements actually help lower bilirubin levels by aiding in the excretion of bilirubin through stool, so this would not increase jaundice risk.

D. "This is because your baby's liver is not yet efficient at breaking down red blood cells.": Newborns often experience physiological jaundice because their immature livers cannot efficiently process the breakdown products of red blood cells, leading to elevated bilirubin levels in the blood.

View Question and Answer

A nurse is assisting with the care of a client.

Select the 4 responsibilities the nurse has in relation to the client's advance directives.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about home infection prevention with a client who is HIV positive. Which of the following statements by the client indicates an understanding of the teaching

Correct Answer is B

Explanation

A nurse is reinforcing teaching with new parents about the provider's prescription for a serum bilirubin test. Which of the following statements should the nurse include in the explanation?

Correct Answer is D

Explanation

A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate. The nurse notes clots and dark red blood in the catheter collection bag. Which of the following actions should the nurse take?

A nurse is assisting with the care of a client. Select the 4 responsibilities the nurse has in relation to the client's advance directives.

The nurse is continuing to assist with the care of the client. The nurse is assisting with initiating the client's plan of care. Which of the following interventions should the nurse include? Select all that apply.

A nurse is administering an enteric-coated medication to an adult client who has right-sided weakness and is having difficulty swallowing tablet. Which of the following actions should the nurse take?

A nurse is assisting in the care of a client who is on isolation for an infection with vancomycin-resistant enterococcus (VRE). Which of the following actions should the nurse take to prevent the spread of infection?

A nurse is reinforcing teaching with a client who has an open leg wound and is experiencing difficulty healing. The nurse should encourage the client to increase which of the following nutrients in his diet?

A nurse is caring for a client who has acute appendicitis and speaks a different language than the nurse. The client is scheduled to undergo an appendectomy. Which of the following actions should the nurse take? (Select all that apply.)