A post-operative patient is receiving opioid analgesics for pain management. Which assessment would alert the nurse to contact the provider?

BP of 120/80, pulse of 100, respiratory rate of 18

BP of 104/72, pulse rate of 80, respiratory rate of 24

BP of 110/60, pulse of 70, respiratory rate of 14

BP of 90/50, pulse of 120, respiratory rate of 10

Answer and Explanation

The Correct Answer is D

A. BP of 120/80, pulse of 100, respiratory rate of 18: This assessment is within normal limits, although the pulse is slightly elevated. It is not immediately concerning for opioid toxicity or complications.

B. BP of 104/72, pulse rate of 80, respiratory rate of 24: This assessment shows a normal BP and pulse, though the respiratory rate is slightly elevated. A rate of 24 could be an expected finding in some patients, especially after surgery, but it does not indicate an immediate risk related to opioid use.

C. BP of 110/60, pulse of 70, respiratory rate of 14: This assessment shows normal vital signs for a post-operative patient. The respiratory rate of 14 is within normal range, and there is no indication of opioid-related respiratory depression or other complications.

D. BP of 90/50, pulse of 120, respiratory rate of 10: A low BP (90/50), elevated pulse (120), and a low respiratory rate (10) are signs of potential opioid overdose or severe sedation. Respiratory depression is a serious side effect of opioids, and the nurse should contact the provider immediately as the patient may be at risk of respiratory failure or shock.

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Correct Answer is D

Explanation

A. Weight: Weight changes can occur due to fluid shifts and edema, but it is not a primary indicator of adequate fluid resuscitation. In burn patients, weight fluctuation may not reliably reflect the effectiveness of fluid replacement.

B. Urine output: Urine output is closely monitored in burn patients for signs of fluid resuscitation adequacy. However, if urine output continues to decrease (instead of increasing), it suggests worsening kidney perfusion and fluid depletion.

C. BP: In burn patients, low blood pressure is a sign of fluid loss and inadequate perfusion. While blood pressure will eventually improve with successful fluid resuscitation, a further decrease in BP would indicate worsening shock and fluid deficit, not adequate resuscitation.

D. Heart rate: A decrease in heart rate would indicate that the body is no longer compensating for hypovolemia and shock. Tachycardia is a common response to fluid loss and hypotension in burn patients, and as fluid resuscitation is effective, the heart rate should begin to decrease toward normal levels.

A. Potassium 10 meq IV mini bag B. Warfarin 5mg by mouth C. Regular insulin 5 units subcutaneously D. Discontinue indwelling catheter

Correct Answer is B

Explanation

A. Potassium 10 meq IV mini bag: The potassium level is at the lower end of the normal range (3.5 mEq/L), but it is not critically low. Potassium supplementation may be needed, but it is not as urgent as managing the elevated INR and low platelet count.

B. Warfarin 5mg by mouth: The patient's INR is elevated at 5.0 (normal range: 2.0-3.0), which significantly increases the risk of bleeding, especially with low platelet levels (50,000/mm3, normal range: 150,000-450,000/mm3). Given the critical low platelets and elevated INR, this order should be brought to the provider's attention to reduce the bleeding risk.

C. Regular insulin 5 units subcutaneously: The patient’s blood glucose is elevated at 240 mg/dL, but insulin administration at 5 units is appropriate for the patient's condition and not an immediate concern compared to the bleeding risk from Warfarin.

D. Discontinue indwelling catheter: The catheter is scheduled for discontinuation, but this is not as urgent as addressing the bleeding risk associated with the elevated INR and low platelet count.

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A post-operative patient is receiving opioid analgesics for pain management. Which assessment would alert the nurse to contact the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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