A nurse is caring for a client who is postoperative and is receiving opioid analgesics. Which of the following findings should the nurse report to the provider?
Oral temperature 37.4° C (99.3° F)
BP 130/84 mm Hg
Heart rate 88/min
Respiratory rate 10/min
The Correct Answer is D
A. Oral temperature 37.4°C (99.3°F): This is a low-grade fever and is generally not concerning unless it increases or persists. It could be related to the body’s response to surgery but does not require immediate reporting to the provider.
B. BP 130/84 mm Hg: This is a normal blood pressure for most adults and does not indicate an issue. There is no immediate concern for the nurse to report this to the provider.
C. Heart rate 88/min: A heart rate of 88 beats per minute is within normal range for an adult and does not require reporting to the provider.
D. Respiratory rate 10/min: A respiratory rate of 10/min is significantly below the normal range for an adult (12-20 breaths per minute) and could indicate respiratory depression, a common side effect of opioid analgesics. This is a serious finding and should be reported to the provider immediately for further evaluation and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Set the suction device to 120 mm Hg: For nasopharyngeal suctioning in adults, the suction pressure should typically be set between 100 and 120 mm Hg to prevent injury to the mucous membranes while effectively clearing secretions.
B. Apply suction to the catheter during insertion: Suction should not be applied during insertion of the catheter, as this can cause trauma to the mucous membranes. Suctioning should only occur when the catheter is in the appropriate position and being withdrawn.
C. Have the client tuck his chin to his chest during suctioning: The client should not tuck the chin to the chest during suctioning. Instead, the client should be asked to either cough or breathe normally. Tucking the chin may obstruct the airway and make suctioning difficult.
D. Apply a petroleum-based lubricant to the catheter: Petroleum-based lubricants should not be used as they can cause a fire hazard when oxygen is present. Instead, a water-soluble lubricant should be applied to the catheter if needed.
Correct Answer is C
Explanation
A. "My hearing has improved since I got my hearing aids.": This statement reflects a positive adaptation to aging, showing that the client is accepting the use of hearing aids to improve hearing. It does not suggest body image issues.
B. "My wrinkled hands show how hard I've worked all my life.": This indicates the client has a positive view of their aging body, interpreting wrinkles as a reflection of life experiences and hard work. It shows an acceptance of physical changes.
C. "I avoid going out because I sometimes have problems with incontinence.": This suggests the client feels embarrassed or self-conscious about incontinence, which is often associated with an impaired body image. The client is avoiding social situations due to this physical issue, which can lead to feelings of shame and isolation.
D. "These lines in my face reveal a part of my character.": This statement demonstrates a positive acceptance of the physical changes associated with aging. The client views facial lines as a sign of character, not a source of distress, indicating a healthy body image.
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