A nurse is collecting data from an adolescent who is postoperative following a cesarean birth and is receiving morphine for pain. Which of the following findings is the nurse's priority?
Urinary retention
Respiratory rate 11/min
BP 105/62 mm Hg
Blurred vision
The Correct Answer is B
A) Incorrect- Urinary retention can be a concern but is not as immediately life-threatening as respiratory depression.
B) Correct - A respiratory rate of 11/min is significantly lower than the normal range and indicates respiratory depression, which can be life-threatening. It requires immediate attention.
C) Incorrect- A blood pressure of 105/62 mm Hg is within a normal range for an adolescent and does not require immediate intervention.
D) Incorrect- Blurred vision might be a side effect of medications, but respiratory depression takes priority due to its potential to lead to serious complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct- Intrauterine devices (IUDs) have one of the lowest failure rates among contraceptive methods. They are highly effective at preventing pregnancy.
B) Incorrect- Diaphragms have a higher failure rate compared to IUDs.
C) Incorrect- Oral contraceptives have a failure rate slightly higher than IUDs due to the potential for missed doses.
D) Incorrect- Contraceptive sponges have a higher failure rate compared to IUDs.
Correct Answer is C
Explanation
A) Incorrect- Terbutaline is a tocolytic medication used to relax uterine muscles and inhibit contractions, not to treat an ectopic pregnancy.
B) Incorrect- Magnesium sulfate is used to prevent seizures in clients with preeclampsia, not to treat ectopic pregnancies.
C) Correct - Methotrexate is often used to treat unruptured ectopic pregnancies in the early stages by inhibiting the growth of trophoblastic tissue.
D) Incorrect- Calcium gluconate is used to treat magnesium toxicity and other conditions related to calcium imbalance, not to treat ectopic pregnancies.
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