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 D
Explanation
A. A community health nurse can provide education, medication management, and health monitoring, but they do not specifically focus on ADL assistance.
B. Respite care provides temporary relief for caregivers, but it does not directly help the client develop skills to maintain independence.
C. A dietitian focuses on nutritional needs and meal planning, but this does not directly address the increased difficulty with ADLs.
Correct Answer is C
Explanation
A. Place multiple smoke detectors in the same area of the home. Smoke detectors should be placed in different areas, especially near bedrooms, in hallways, and on every level of the home, rather than clustering them in one area.
B. Change the batteries in smoke detectors every 2 years. Batteries should be changed at least once a year, and the smoke detector should be tested monthly to ensure functionality.
C. Cover the nose and mouth with a damp cloth before exiting a smoke-filled area. Using a damp cloth helps filter out some smoke and toxic fumes, reducing inhalation of harmful particles.
D. Open a window to let smoke out before leaving the home. Opening a window can increase oxygen flow, which may intensify the fire rather than help in an evacuation. Instead, the priority should be to evacuate immediately and call emergency services.
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