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 A
Explanation
Choice A rationale
Choosing foods high in fiber and low in fat is beneficial for maintaining a healthy diet. High-fiber foods help improve digestion, regulate blood sugar levels, and reduce the risk of heart disease, while low-fat foods help control calorie intake and support weight management.
Choice B rationale
Including a variety of fruits and vegetables is crucial for a balanced diet as they provide essential vitamins, minerals, and antioxidants. However, it does not address the need to limit fat intake, which is also important for overall health.
Choice C rationale
Drinking plenty of water throughout the day is vital for staying hydrated and supporting bodily functions. Nevertheless, it does not directly impact the intake of fiber and fat, which are key components of a healthy diet.
Choice D rationale
Limiting the intake of sugary and processed foods is important for reducing the risk of various health issues such as obesity, diabetes, and heart disease. However, it does not emphasize the importance of high fiber and low-fat foods, which are essential for a healthy diet. o
Correct Answer is ["A","B"]
Explanation
Choice A rationale: It is important for the client to complete the full course of antibiotics to ensure the infection is fully treated and to prevent antibiotic resistance.
Choice B rationale: Keeping the oxygen delivery system at least 8 feet from any heat source is crucial for safety to prevent the risk of fire.
Choice C rationale: Decreasing the steroid dose each day is not relevant in this case since there is no mention of the client being on steroids for the pneumonia treatment.
Choice D rationale: While taking antibiotic medication with or without food can be important, the specific instruction for this medication should be based on the pharmacist's or provider's recommendation. However, this option is not the best answer compared to completing the full course of antibiotics.
Choice E rationale: Adjusting the oxygen flow rate as needed to ease breathing should only be done under medical supervision. Clients are typically instructed to use a prescribed oxygen flow rate, and adjustments should not be made without consulting a healthcare provider.
Choice F rationale: Taking steroid medication in the morning can help reduce side effects, but again, this option is not relevant since the client's current treatment does not include steroids.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.