A nurse is caring for a postoperative male client in the surgical unit. The following exhibits are available for review
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. Select all that apply
Respiratory rate 10/min
Pulse oximetry 88% on room air
Blood pressure 99/46 mm Hg
Morphine 10 mg administered subcutaneously
Correct Answer : A,B,D
Choice A rationale: The client’s respiratory rate of 10/min is below the normal range (12-20 breaths per minute). This suggests respiratory depression, which can be caused by opioid medications like morphine.
Choice B rationale: The client’s pulse oximetry reading of 88% on room air is lower than the normal range (95%-100%). This indicates hypoxemia, which may be due to respiratory depression from the morphine.
Choice C rationale: Although the blood pressure of 99/46 mm Hg is low, it might be acceptable for this client postoperatively. However, it does not require immediate intervention compared to the other choices.
Choice D rationale: The administration of morphine 10 mg subcutaneously needs further action because the client is showing signs of opioid overdose (e.g., respiratory depression, hypoxemia). This necessitates reassessment and potential adjustment of the medication dosage or frequency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A repressed grief response, where an individual avoids expressing their grief, is considered delayed grief, not exaggerated grief. This can manifest as physical symptoms or psychological issues later on.
Choice B rationale
Grief that begins following a terminal diagnosis is anticipatory grief, which is a normal response as individuals begin to process the impending loss. It prepares them emotionally for the eventual death.
Choice C rationale
Exaggerated grief involves intense, prolonged, and often harmful reactions such as self-destructive behaviors. This type of grief can significantly impair a person's ability to function and may require professional intervention.
Choice D rationale
A grief response triggered by a secondary loss (e.g., loss of job or home) is known as cumulative grief. While it complicates the grieving process, it does not inherently lead to the exaggerated, self-destructive behaviors seen in exaggerated grief.
Correct Answer is D
Explanation
Choice A rationale
Isopropyl alcohol is effective for general disinfection but is not the best choice for cleaning blood spills because it does not completely eliminate all pathogens, especially certain viruses like hepatitis B.
Choice B rationale
Hydrogen peroxide is not typically used for blood spills as it is less effective against certain pathogens compared to other disinfectants and can potentially damage surfaces over time.
Choice C rationale
Chlorhexidine gluconate is used for skin antisepsis rather than environmental disinfection. It is not the best option for cleaning blood spills due to its limited efficacy against all bloodborne pathogens.
Choice D rationale
Chlorine bleach is the recommended solution for cleaning blood spills as it is highly effective in killing a wide range of pathogens, including viruses like HIV and hepatitis B, ensuring a safe and sanitized area.
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