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 D
Explanation
Choice A rationale
Placing one hand over the other against the upper body of the gown increases the risk of contamination. The sterile field must be maintained by keeping hands in a position where they are less likely to come into contact with non-sterile surfaces.
Choice B rationale
Clasping hands behind the body at the waist can also lead to contamination, as the hands may inadvertently touch the gown, which may not be sterile in that area. It’s essential to keep hands in a position where they are less likely to become contaminated.
Choice C rationale
Keeping arms at the sides with hands in a relaxed position might cause hands to brush against non-sterile surfaces or clothing, leading to contamination. Therefore, this position is not recommended for maintaining sterility.
Choice D rationale
Interlocking fingers and holding hands away from the body above the waist is the proper technique for maintaining sterility. This position ensures that the hands are kept in the sterile field and away from non-sterile surfaces, reducing the risk of contamination.
Correct Answer is C
Explanation
Choice A rationale
Orthostatic hypotension is characterized by a sudden drop in blood pressure when standing up, often due to dehydration, medication side effects, or autonomic dysfunction. While concerning, it is not a direct risk factor for cardiovascular disease.
Choice B rationale
A BMI of 24 is within the normal range (18.5–24.9) and is not considered a risk factor for cardiovascular disease. Maintaining a healthy BMI is part of cardiovascular disease prevention.
Choice C rationale
Type 1 diabetes mellitus significantly increases the risk of cardiovascular disease due to its impact on blood vessels and the heart. It is a well-documented risk factor requiring careful management.
Choice D rationale
A family history of osteoporosis is relevant for bone health but does not directly increase the risk of cardiovascular disease. Cardiovascular risk factors are more closely related to metabolic and lifestyle factors.
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