A recent postoperative client is being transferred back to the medical-surgical unit. The client is receiving morphine through a patient-controlled analgesia (PCA) pump. The nurse notes that the client is lethargic, with a blood pressure of 118/66 and respirations of 8. What should the nurse have readily available?

Oxygen and suction equipment

Naloxone

IV fluids

Blood pressure monitor

Answer and Explanation

The Correct Answer is B

Choice A reason: Oxygen and suction equipment support respiratory function but are not the priority for opioid-induced respiratory depression from morphine. Lethargy and low respiratory rate (8 breaths/min) indicate overdose, requiring naloxone to reverse opioid effects first, as hypoxia can persist without addressing the primary cause.

Choice B reason: Naloxone, an opioid antagonist, reverses morphine-induced respiratory depression and lethargy. A respiratory rate of 8 breaths/min signals overdose, risking hypoxia and brain damage. Naloxone restores normal respiration by blocking opioid receptors, making it critical to have readily available for immediate administration in this scenario.

Choice C reason: IV fluids may support blood pressure but are not the priority for opioid-induced respiratory depression. Lethargy and low respiratory rate indicate morphine toxicity, requiring naloxone to reverse effects. Fluids address secondary issues like hypovolemia, not the primary concern of respiratory compromise in this case.

Choice D reason: A blood pressure monitor is unnecessary, as the client’s blood pressure (118/66) is stable. The critical issue is respiratory depression and lethargy from morphine, requiring naloxone. Monitoring blood pressure is secondary to addressing life-threatening respiratory compromise caused by opioid overdose in this postoperative client.

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Correct Answer is A

Explanation

Choice A reason: Hypovolemia is likely, as vomiting and diarrhea cause significant fluid loss, leading to dehydration. Confusion (from cerebral hypoperfusion), elevated temperature (from concentrated blood), and dry mouth (from reduced saliva) reflect low intravascular volume, making this the most fitting diagnosis for the client’s condition.

Choice B reason: Hypernatremia results from excessive sodium relative to water, often from inadequate water intake. Vomiting and diarrhea deplete water and electrolytes, causing hypovolemia, not sodium excess. Confusion and fever align with dehydration, making hypernatremia an incorrect diagnosis in this scenario.

Choice C reason: Hypokalemia may occur with diarrhea due to potassium loss, but confusion, fever, and dry mouth primarily reflect hypovolemia from fluid loss. Potassium loss is secondary, as hypovolemia’s systemic effects are more immediate, making this a less comprehensive diagnosis for the client’s symptoms.

Choice D reason: Metabolic acidosis can occur with diarrhea due to bicarbonate loss, but confusion, fever, and dry mouth primarily reflect hypovolemia from fluid loss. Acidosis may contribute, but hypovolemia drives these systemic signs, making it the more accurate diagnosis in this context.

A. Continue to take the aspirin as ordered. B. Aspirin should be increased until 3 days before surgery, then discontinued until 3 days after surgery. C. Stop taking the aspirin 7 days before the surgery, unless otherwise directed by the physician. D. Take half doses of the aspirin until 1 week after surgery.

Correct Answer is C

Explanation

Choice A reason: Continuing aspirin increases bleeding risk during surgery due to its antiplatelet effect, inhibiting clot formation for 7–10 days. This can lead to excessive intraoperative hemorrhage, making it an incorrect instruction, as stopping aspirin is standard to ensure hemostasis.

Choice B reason: Increasing aspirin heightens bleeding risk, as its antiplatelet effect persists for 7–10 days. Discontinuing only 3 days prior is insufficient, and resuming 3 days post-surgery risks bleeding, making this an incorrect and unsafe instruction for surgical preparation.

Choice C reason: Stopping aspirin 7 days before surgery is standard, as its antiplatelet effect lasts 7–10 days, reducing bleeding risk. This allows platelet function to normalize, preventing hemorrhage, making it the correct instruction, with physician guidance for conditions like cardiac stents.

Choice D reason: Taking half doses of aspirin does not mitigate its antiplatelet effect, which persists for 7–10 days, increasing surgical bleeding risk. This is insufficient to ensure hemostasis, making it an incorrect instruction compared to stopping aspirin 7 days prior for safer outcomes.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client’s spouse became alarmed when the client demonstrated confusion and elevated temperature and reported “dry mouth.” The nurse suspects the client is experiencing which condition?

Correct Answer is A

Explanation

The nurse is educating a client scheduled for elective surgery. The client currently takes aspirin daily. What education will the nurse provide regarding this medication?

Correct Answer is C

Explanation

A client with pneumonia is experiencing ineffective airway clearance related to pain, fatigue, and толстые secretions. Which evaluation best indicates to the nurse a therapeutic response to treatment?

A nurse is caring for a client who has pneumonia. The nurse notes that the client has thick secretions and needs to thin them. What intervention will help thin the secretions?

A nurse is assessing a client who has a pneumothorax with a chest tube in place. What assessment would warrant notifying the provider?

A nurse is witnessing a client sign the consent form for surgery. After signing the consent form, the client starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate?

A client has a sodium level of 121 mEq/L. What is the priority nursing intervention?

The nurse is reviewing the laboratory results of a client. Which result should the nurse identify as the priority finding?

The nurse is preparing to administer an intravenous vesicant medication to a client. Which of the following findings should the nurse identify as a complication of extravasation?

A nurse is caring for a one-day postoperative client. Which of the following would be the priority for the nurse?