A nurse is collecting data from a client who is receiving hydromorphone for pain management. For which of the following findings should the nurse notify the provider?
Oxygen saturation 95%
Respiratory rate 14/min
Urinary output 160 mL/8hr
Blood pressure 108/58 mm Hg
The Correct Answer is C
A. Oxygen saturation 95%: An oxygen saturation of 95% is within normal limits for most clients and does not indicate respiratory compromise. No immediate provider notification is necessary based solely on this oxygen saturation level during opioid therapy.
B. Respiratory rate 14/min: A respiratory rate of 14 breaths per minute is normal. Significant respiratory depression from opioids like hydromorphone would typically be indicated by a rate lower than 12 breaths per minute.
C. Urinary output 160 mL/8 hr: Urinary output should be at least 30 mL/hr. A total of 160 mL in 8 hours is significantly low, suggesting possible urinary retention or decreased renal perfusion, both of which can be side effects of opioid use and should be reported promptly.
D. Blood pressure 108/58 mm Hg: While this blood pressure is on the lower side, it is not critically low for many adults. Unless the client is symptomatic with dizziness or fainting, this blood pressure alone does not require immediate provider notification.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Your baby is at a higher risk because they were born with congenital dermal melanocytosis.": Congenital dermal melanocytosis, also known as Mongolian spots, are harmless pigmented birthmarks and are unrelated to bilirubin levels or jaundice risk in newborns.
B. "This is because your baby is breastfed. You should start supplementing with formula.": Breastfeeding itself is not a reason to stop or supplement with formula unless medically necessary. Breastfeeding jaundice can occur, but proper feeding techniques and frequency usually manage it without needing supplementation.
C. "Your baby is at a higher risk because they have had four bowel movements in the first day of life.": Frequent bowel movements actually help lower bilirubin levels by aiding in the excretion of bilirubin through stool, so this would not increase jaundice risk.
D. "This is because your baby's liver is not yet efficient at breaking down red blood cells.": Newborns often experience physiological jaundice because their immature livers cannot efficiently process the breakdown products of red blood cells, leading to elevated bilirubin levels in the blood.
Correct Answer is C
Explanation
A. “I may notice an increase in the firmness of my breasts.”: During menopause, breasts typically become less firm and more fatty due to decreased estrogen levels. Loss of glandular tissue and changes in connective tissue elasticity cause breasts to feel softer, not firmer.
B. "My estrogen levels will elevate”: Estrogen levels decline significantly during menopause, not elevate. This hormonal decrease leads to many of the physical and emotional symptoms associated with menopause, including hot flashes, vaginal dryness, and bone density loss.
C. "I may experience more vaginal dryness.": Vaginal dryness is a common and expected symptom during menopause due to the reduction in estrogen. Lower estrogen levels cause thinning and decreased lubrication of the vaginal tissues, often resulting in discomfort during intercourse and increased risk of irritation or infection.
D. "I may become cold more often.": Clients undergoing menopause typically experience hot flashes and night sweats, not an increased tendency to feel cold. Hot flashes are sudden sensations of heat and are one of the most recognized and frequent symptoms of menopausal transition.
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