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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Clammy skin may indicate various conditions, including shock or anxiety, but it is not

specifically indicative of deep-vein thrombosis. It is not the most concerning finding in this scenario.
B. Tortuous veins refer to veins that are twisted or enlarged, often visible on the surface of the skin. While tortuous veins may be present in some cases of deep-vein thrombosis, they are not a definitive sign and are less concerning than other symptoms.
C. Bradycardia, a slower than normal heart rate, is not typically associated with deep-vein

thrombosis. It may indicate other cardiovascular or systemic issues but is not the priority in this situation.
D. Calf swelling, especially unilateral swelling, is a common and concerning sign of deep-vein

thrombosis. It results from impaired venous return due to the presence of a blood clot in the deep veins of the leg. Prompt reporting of this finding is essential for further evaluation and
intervention.

A. Prepare a dry work surface above the waist level. B. Open the outside cover of the sterile kit and remove the dust cover. C. Grasp the outermost flap of the sterile kit while opening away from the body. D. Open each side flap of the sterile kit individually while pulling to the side. E. Open the innermost lower flap of the sterile kit while standing away from the sterile field.

Correct Answer is A, B, C, D, E

Explanation

To set up a sterile field for changing a dressing on an abdominal wound, the nurse should perform the following steps in sequence: First, prepare a dry work surface above waist level to ensure that the sterile field is maintained at a height that minimizes the risk of contamination. Next, open the outside cover of the sterile kit and carefully remove the dust cover, which protects the inner contents from contamination. Then, grasp the outermost flap of the sterile kit and open it away from the body, avoiding any abrupt movements that could compromise sterility. After that, open each side flap of the sterile kit individually, pulling them to the side and making sure not to reach over the sterile field. Finally, open the innermost lower flap of the sterile kit while standing away from the sterile field to prevent contamination from the nurse's clothing or body. These steps help maintain the sterility of the dressing and the instruments, which is crucial for preventing infection at the wound site.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider?

Correct Answer is D

Explanation

A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is A, B, C, D, E

Explanation

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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.