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.

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Correct Answer is D

Explanation

Choice A rationale

Verifying the bilirubin level of the tube contents is not a standard or reliable method for checking the placement of a feeding tube. Bilirubin is a bile pigment found in the liver and bile ducts, and its levels are not indicative of tube placement in the gastrointestinal tract.

Choice B rationale

Checking the pH level of gastric contents can help determine if the tube is in the stomach, but it is not the most reliable method. Gastric pH is typically acidic (1.5-3.5), but the pH can vary, and this method does not rule out respiratory placement or other incorrect placements.

Choice C rationale

Auscultating for air insufflation involves listening for the sound of air injected through the tube into the stomach. However, this method is not reliable as it does not confirm the exact location of the tube and can give false positives if the tube is in the esophagus or respiratory tract.

Choice D rationale

Requesting a chest x-ray is the most reliable method for verifying feeding tube placement. It provides a clear visual confirmation of the tube's location, ensuring it is correctly positioned in the stomach or small intestine and not in the respiratory tract or other incorrect locations.

A. "Tell me more about what happens at mealtime.”. B. "They may need a feeding tube.”. C. "Have you tried offering different foods?" D. "Let's discuss ways to encourage their appetite.”.

Correct Answer is A

Explanation

Choice A rationale

"Tell me more about what happens at mealtime.”. This response encourages the caregiver to share detailed information about mealtime routines and behaviors, which can help the nurse identify underlying issues and suggest appropriate strategies.

Choice B rationale

"They may need a feeding tube.”. This suggestion can be alarming and may not be appropriate without understanding the full context of the client's eating habits. Feeding tubes are considered only when other interventions have failed.

Choice C rationale

"Have you tried offering different foods?" While this might be helpful, it does not address the underlying issues. Gathering more information about the current mealtime situation is crucial before suggesting specific interventions.

Choice D rationale

"Let's discuss ways to encourage their appetite.”. This response is proactive but still doesn't gather enough information about the current situation. Understanding the specifics of mealtime behavior is necessary to provide tailored advice.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is checking for proper placement of a feeding tube.Which of the following methods is the most reliable for verification of tube placement?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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