A nurse is caring for a postoperative male client in the surgical unit. The following exhibits are available for review

Exhibits

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

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","C","D"]

Explanation

Choice A rationale

A client who receives burns from a heating pad has experienced harm due to the healthcare setting or treatment. An incident report should be completed to document the injury and investigate the cause to prevent future occurrences.

Choice B rationale

A client's dissatisfaction with meal temperature does not typically require an incident report unless it leads to significant issues such as foodborne illness or other adverse effects. It is usually managed through the facility's complaint process.

Choice C rationale

If a client becomes disoriented and falls out of bed, it is crucial to complete an incident report to document the event, assess the cause, and implement measures to prevent similar incidents. This helps ensure client safety and continuous quality improvement.

Choice D rationale

When a client's visitor becomes dizzy and faints in the client's room, an incident report should be completed to document the occurrence and initiate an investigation into the cause. This helps in providing appropriate care and preventing future incidents.

Choice E rationale

A client's inability to afford recommended physical therapy is an important issue but does not typically require an incident report. This situation should be addressed through social services or financial counseling to find a solution.

A. Inject air into the ampule prior to drawing the medication into a syringe. B. Add 0.5 mL of diluent to the medication. C. Use a filter needle to aspirate the medication. D. Cleanse the tip of the ampule with an alcohol swab after opening.

Correct Answer is C

Explanation

Choice A rationale

Injecting air into the ampule prior to drawing the medication into a syringe is incorrect because ampules are sealed glass containers, and injecting air could cause the liquid to spill out due to pressure changes.

Choice B rationale

Adding 0.5 mL of diluent to the medication is not appropriate for most medications in ampules unless specifically instructed by the medication guidelines. Ampules typically contain ready-to-use medication.

Choice C rationale

Using a filter needle to aspirate the medication is the correct action. A filter needle is used to prevent any glass particles from being drawn into the syringe, ensuring the medication is safe for administration.

Choice D rationale

Cleansing the tip of the ampule with an alcohol swab after opening is unnecessary because the ampule's contents are sterile and the risk of contamination is minimized if the ampule is handled correctly.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients.For which of the following situations should the nurse complete an incident report? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

A nurse is preparing to administer a medication from an ampule.Which of the following is an appropriate action for the nurse to take?

Correct Answer is C

Explanation

A nurse is assisting with scoliosis screenings for students at a public school.Which of the following findings should the nurse recognize as an indication of scoliosis?

A nurse is participating in a group discussion about complicated grief associated with loss.Which of the following should the nurse identify as an example of exaggerated grief?

A charge nurse is observing a newly licensed nurse who is caring for a group of clients.Which of the following statements by the newly licensed nurse indicates an understanding of infection control principles?

A nurse in a long-term care facility is caring for a client who has a tracheostomy.Which of the following actions should the nurse take?

A nurse is caring for a young adult client who is postoperative and requires physical therapy, pain management, and dietary advancement.The nurse enters the client's room and finds them dressing and stating that they are going home.Which of the following actions should the nurse take?

A nurse is reinforcing teaching with an older adult client about the aging process.The nurse should instruct the client that which of the following physiological changes are part of the aging process? (Select all that apply.)

A nurse is reinforcing teaching about advance directives with a client who has terminal colorectal cancer.Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, "I'm not going to take this medication because it makes me sick and dizzy.”. Which of the following actions should the nurse take first?