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 C
Explanation
A. Securing the restraints with a square knot may be too tight and could restrict circulation or cause injury. Using a quick-release knot is preferable to allow for quick removal if necessary.
B. While it is important to assess the client's range of motion regularly, this action does not directly address the proper application of the restraints.
C. This is the correct action to ensure that the restraints are not too tight, allowing for adequate circulation and preventing injury. The ability to fit two fingers under the restraints ensures that they are applied with proper tension.
D. Requesting a prescription renewal from the provider every 36 hours may be necessary according to facility policy, but it does not directly address the proper application of the
restraints.
Correct Answer is B
Explanation
A. While repositioning is important for comfort and preventing pressure ulcers, repositioning every 4 hours may not be sufficient, and it does not directly address the client's dyspnea.
B. Circulating air with a fan can help reduce the sensation of breathlessness and improve comfort for clients experiencing dyspnea. This non-invasive measure can be effective in relieving symptoms.
C. Placing the head of the bed flat is generally not recommended for clients with dyspnea, as it can worsen breathing difficulties. Elevating the head of the bed is usually more helpful.
D. Frequent oral care is important for maintaining comfort, especially in end-of-life care, but every 8 hours might not be sufficient. More frequent oral care is typically needed, and while important, this does not directly address dyspnea.
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