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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Have you thought about moving to a new neighborhood?": This response may dismiss the client’s feelings and doesn't directly address the anxiety. It also suggests an unrealistic solution without understanding the root cause of the client's anxiety.
B. "Let's discuss how you feel when you leave your house.": This response encourages open communication and invites the client to express their feelings. It focuses on understanding the client’s anxiety, which is the first step in addressing and managing it.
C. "Tell me why you have developed an aversion to leaving your house.": While exploring the cause of the anxiety is important, this response may come across as judgmental and could make the client feel defensive. A more open and empathetic approach would help the client feel more comfortable discussing their feelings.
D. "Have you tried leaving your house just once per day?": While this might be helpful in a later stage of treatment, it doesn't address the underlying anxiety and could be perceived as a directive instead of an empathetic, open-ended question to explore the client's emotions and experiences.
Correct Answer is D
Explanation
A. "I will take my inhaler treatment before each meal and at bedtime.": Budesonide is a corticosteroid used for long-term control of asthma, not for timing around meals. It is usually taken at set times daily to maintain airway inflammation control, not specifically related to mealtimes or bedtime alone.
B. "I should use my inhaler before exercising.": Using an inhaler before exercise is a strategy typically applied to short-acting bronchodilators like albuterol to prevent exercise-induced bronchospasm. Budesonide is a maintenance medication and is not intended for pre-exercise use.
C. "I should use my inhaler when I have an asthma attack.": Budesonide is not a rescue inhaler and should not be used during an acute asthma attack. Quick-relief inhalers like albuterol are used for immediate symptom management during asthma exacerbations.
D. "I will rinse my mouth and gargle with water after each inhaler treatment.": Rinsing the mouth after using an inhaled corticosteroid like budesonide is important to prevent oral thrush (candidiasis). This action demonstrates correct understanding of medication use and necessary precautions.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.