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. Monthly breast self-examinations are valuable, but the recommended starting age is typically earlier, around age 20, regardless of family history.
B. While regular breast examinations by a healthcare provider are important, they may not be sufficient as the primary screening method for breast cancer.
C. Breast ultrasound may be used as a supplementary screening tool but is not typically recommended as the primary screening method.
D. Mammograms are the primary screening method for breast cancer, and for women without a family history, they are typically recommended to start at age 40, although guidelines may vary slightly.
Correct Answer is ["12.5"]
Explanation
To calculate the correct dosage, first convert the child's weight from pounds to kilograms. The child weighs 55 lb, which is approximately 55 ÷ 2.2 = 25kg
The prescribed dose is 50 mg/kg/day, so for a 25 kg child, this would be 25 kg × 50 mg = 1250 mg/day.
Since this is divided into 4 equal doses, each dose would be 1250 mg ÷ 4 = 312.5 mg. 125mg= 5ml
312.5mg= 312.5X5/125
=12.5ml
Therefore, the nurse should administer 12.5 mL per dose.
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