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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Hypertension: Hyponatremia typically leads to hypotension due to fluid shifts out of the vascular space rather than hypertension, especially if it is associated with hypovolemia. Low sodium levels can reduce blood volume and pressure, making hypertension an unlikely finding in this condition.

B. Muscle cramps: Muscle cramps are a common symptom of hyponatremia due to disrupted electrolyte balance affecting neuromuscular function. Low sodium levels impair muscle contraction and nerve signal transmission, leading to cramps, weakness, and fatigue.

C. Blurred vision: Blurred vision is not a typical manifestation of hyponatremia. While severe hyponatremia can cause neurological symptoms like confusion or seizures, visual disturbances like blurred vision are not primary signs linked to sodium imbalance.

D. Constipation: Constipation is more often associated with dehydration, immobility, or other electrolyte imbalances such as hypercalcemia. Hyponatremia primarily affects neuromuscular and central nervous system function rather than gastrointestinal motility.

A. WBC count 12,000/mm3 (5,000 to 10,000/mm3) B. Temperature 37.8° C (100° F) C. Respiratory rate 16/min D. Hgb 8 g/dL (less than 11 g/dL)

Correct Answer is D

Explanation

A. WBC count 12,000/mm³: A mild elevation in white blood cell count is expected within the first few days postpartum as part of the normal inflammatory response due to the stress of labor and delivery.. A count of 12,000/mm³ is not alarming and does not necessarily indicate infection or a complication.

B. Temperature 37.8°C (100°F): A low-grade temperature elevation within the first 24 hours postpartum is common due to hormonal shifts, dehydration, or exertion from labor. This finding would not immediately require provider notification unless it persists or rises higher.

C. Respiratory rate 16/min: A respiratory rate of 16 breaths per minute is within normal adult limits and does not suggest respiratory distress or any postpartum complication, so no intervention is required for this finding.

D. Hgb 8 g/dL: A hemoglobin level of 8 g/dL is significantly low and can indicate postpartum hemorrhage or significant blood loss. This degree of anemia should be reported promptly to the provider to assess the need for interventions such as blood transfusion or iron supplementation.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has hyponatremia. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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