A nurse is caring for a client who is postoperative.
Medication Administration Record
0830:
Morphine 10 mg subcutaneous every 3 hr PRN pain
What documentation in the client's medical record requires further action by the nurse.
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
Correct Answer : B,C,D
A. A temperature of 37.5° C (99.5° F) is slightly elevated but can be expected postoperatively and does not typically require immediate intervention.
B. The client being difficult to arouse is concerning following opioid administration, as it may indicate over-sedation or the onset of respiratory depression. This requires immediate nursing action.
C. A respiratory rate of 10/min is low and can be a sign of opioid-induced respiratory depression, especially when combined with difficulty arousing the client. This is a critical value that
necessitates prompt nursing assessment and intervention.
D. Pulse oximetry of 88% on room air is below the normal range and indicates hypoxemia. This is a serious finding that requires immediate action to improve the client's oxygenation.
E. Pupils that are 3 mm, equal, and reactive to light, along with a blood pressure of 99/46 mm Hg, while on the lower side, are not as immediately concerning as the respiratory rate and level of consciousness.
F. A heart rate of 61/min is within normal limits and does not typically require intervention unless there are other signs of hemodynamic instability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Room number: Room numbers are not unique identifiers and may change depending on the client's location within the facility.
B. Medical diagnosis: Medical diagnoses are not unique identifiers and may apply to multiple clients.
C. Age: Age alone is not a reliable identifier, as multiple clients may share the same age.
D. Photograph: A photograph is a reliable and unique identifier that can help ensure the correct client receives the correct medications. It allows the nurse to visually confirm the client's identity before administering medications.
Correct Answer is D
Explanation
A. Clients with expressive aphasia have difficulty expressing themselves verbally but can often understand spoken language. It's important for the nurse to provide the teaching without
expecting a verbal response from the client. The client may still benefit from receiving information even if they cannot verbally respond.
B. Speaking loudly is not helpful for clients with expressive aphasia and may increase confusion or frustration. The nurse should speak clearly and at a normal volume.
C. Facial gestures can aid in communication for clients with expressive aphasia by providing additional cues. The nurse should use facial expressions to enhance communication.
D.Clients with expressive aphasia have difficulty expressing themselves verbally. Assessing the client's ability to use alternative communication methods, such as a communication board, can help facilitate effective communication and understanding of the teaching.
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