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. Leg cramps: Leg cramps are a common and expected discomfort during the later stages of pregnancy. They usually result from changes in circulation, pressure from the growing uterus, or altered calcium and magnesium levels.

B. Blurred vision: Blurred vision is a concerning finding in pregnancy as it can be a sign of preeclampsia, a serious hypertensive disorder that poses risks to both the mother and fetus. It requires immediate evaluation by the provider.

C. Urinary frequency: Urinary frequency is a common symptom in late pregnancy due to the pressure of the enlarging uterus on the bladder. It is typically expected unless accompanied by signs of infection.

D. Gingivitis: Gingivitis can occur during pregnancy due to hormonal changes that affect gum tissue. While it should be managed with good oral hygiene, it is not an urgent concern requiring immediate reporting.

A. "Have you thought about moving to a new neighborhood?" B. "Let's discuss how you feel when you leave your house." C. “Tell me why you have developed an aversion to leaving your house." D. "Have you tried leaving your house just once per day?"

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.

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 collecting data from a client who is at 35 weeks of gestation. Which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is talking with a client who reports that they have started feeling anxious every time they have to leave their house. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A charge nurse is educating a newly licensed nurse on how to perform a sterile dressing change on a client. Which of the following action indicates an understanding of the teaching?

A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?

A nurse is assisting with planning care for a client who has a new diagnosis of multiple sclerosis. Which of the interventions should the nurse recommend?

A nurse is contributing to the plan of care for a client who has urinary incontinence. Which of the following interventions should the nurse include in the plan?

A nurse is assisting with the care of a client who is pregnant The nurse is reviewing the client's medical record. Select 4 findings that the nurse should identify as a potential prenatal complication.

The nurse is continuing to assist with the care of the client. For each finding, click to specify if the finding indicates that the client's condition has improved or has not changed.

A nurse is assisting with the care of a client who is receiving a PCA pump following a hysterectomy. Which of the following findings should the nurse identify as an indicator of unrelieved pain?

A nurse is assisting in the care of a group of clients in the preoperative unit. Which of the following clients can give informed consent?