The nurse is caring for a postpartum client who is receiving pain medication through an epidural catheter. Which assessment finding should the nurse report immediately to the physician?

Blood pressure: 120/80.

Pain rating of 4 on a scale of 1 to 10.

Pulse rate: 80.

Respiratory rate: 8.

Answer and Explanation

The Correct Answer is D

The nurse should immediately report a respiratory rate of 8 to the physician. A normal respiratory rate for an adult is between 12 and 20 breaths per minute. A respiratory rate of 8 is considered abnormally low and can indicate respiratory depression, which can be a side eﬀect of pain medication delivered through an epidural catheter. It is important for the nurse to report this finding immediately so that appropriate interventions can be taken to ensure the safety of the client.

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Correct Answer is B

Explanation

In the absence of an advance directive, the nurse should call a code ³. This means initiating emergency resuscitation measures to try to revive the client. The other options (Call a partial code, Call the physician, and Call a "slow code") are not appropriate in this situation.

A. Ineﬀective Breathing Pattern as evidenced by cyanotic lips. B. Risk for infection related to recent surgery. C. Nutrition less than adequate related to anxiety as evidenced by weight loss of ten pounds. D. Ineﬀective coping related to depression as evidenced by a suicide attempt. E. Noncompliance (DASH diet) related to denial of having the disease.

Correct Answer is ["A","C","D"]

Explanation

The PED model is a framework for writing nursing diagnoses that stands for Problem, Etiology, and Defining Characteristics. A nursing diagnosis written using the PED model includes a statement of the client's problem (P), the cause or contributing factors of the problem (E), and the observable signs and symptoms that indicate the presence of the problem (D). In this case, options a), c), and d) are examples of nursing diagnoses that demonstrate appropriate use of the PED model. Each of these diagnoses includes a statement of the client's problem, the cause or contributing factors, and the defining characteristics that indicate the presence of the problem.

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The nurse is caring for a postpartum client who is receiving pain medication through an epidural catheter. Which assessment finding should the nurse report immediately to the physician?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a terminal illness without an advance directive stops breathing and does not have a heartbeat. What should the nurse do?

Correct Answer is B

Explanation

The nurse is using the PED model to write a nursing diagnosis. Which nursing diagnoses demonstrate that the nurse used this model appropriately? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

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