A nurse is caring for a client who is postoperative.
Click to highlight the documentation in the client's medical record that requires further action by the nurse. To deselect documentation, click on the documentation again.
Temperature 37.5° C (99.5° F)
Client is difficult to arouse.
Respiratory rate 10/min
Pulse oximetry 88% on room air (95% to 100%)
Pupils are 3 mm, equal, and reactive to light.
Blood pressure 99/46 mm Hg
Heart rate 61/min
Client is difficult to arouse
Respiratory rate 10/min
Pulse oximetry 88% on room air (95% to 100%)
Blood pressure 99/46 mm Hg
The Correct Answer is ["A","B","C"]
Client is difficult to arouse – This is concerning and may indicate opioid overdose or sedation due to the recent administration of morphine. The nurse should assess the client's level of consciousness closely and consider reversal of the opioid (naloxone) if the client's level of sedation is excessive.
Respiratory rate 10/min – This is below the normal respiratory rate (12–20 breaths/min) and could indicate respiratory depression, a common side effect of opioids like morphine. Close monitoring and possible intervention are required.
Pulse oximetry 88% on room air (95% to 100%) – The oxygen saturation is low, which could indicate hypoxemia. The nurse should administer supplemental oxygen and notify the provider.
Other Findings:
Pupils are 3 mm, equal, and reactive to light – This is a normal finding and not concerning for opioid overdose.
Blood pressure 99/46 mm Hg – This is slightly lower than normal but not critically low, considering the client's condition. Morphine can cause hypotension, especially in older adults or hypovolemic clients.
Heart rate 61/min – This is within a normal range for some postoperative patients, especially in a restful state.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Dose The dose (5 mg) is clearly stated.
B. Time The prescription does not specify the frequency (e.g., every 4 hours PRN pain). The nurse should clarify how often the medication should be given.
C. Medication The medication (morphine) is clearly stated.
D. Route The route (IV bolus) is clearly specified.
Correct Answer is C
Explanation
A. Laboratory results Lab results are diagnostic data, not part of the health history. They are obtained separately through testing.
B. Physical examination findings The physical exam is a separate component of the assessment and is not included in the health history, which focuses on subjective data.
C. Health habits The health history includes subjective data provided by the client, such as dietary habits, exercise routine, smoking, alcohol use, sleep patterns, and medication use. This information helps the nurse understand the client’s lifestyle and risk factors.
D. Observed client behaviors While a nurse may take note of behaviors, the health history is based on the client’s self-reported information, not observations.
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