36. A nurse is caring for a client.
Exhibits
Which of the following findings at 1015 requires further action?

(Select all that apply.)

Low back pain

Urine color

Blood pressure

Respiratory rate

Answer and Explanation

Correct Answer : C,D

A.   While low back pain can be concerning, it's not an immediate priority compared to the vital sign changes. However, the nurse should document the pain and ask about its characteristics.
B.   Brown-colored urine can sometimes indicate dehydration or certain medical conditions, requiring follow-up.
C.   A significant drop in blood pressure (74/50 mmHg) indicates hypotension and requires immediate attention.
D.   An increase in respiratory rate (28 breaths/min) suggests the client may be experiencing respiratory distress and needs evaluation.
E.   The client’s oxygen saturation is 95% on room air which is normal.

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Correct Answer is D

Explanation

A. Returning the excess medication to the secure cabinet is not appropriate as it can lead to contamination and safety issues.
B. Saving the excess medication for the next administration is not safe practice due to potential contamination.
C. Placing the excess medication in the sharps container is not the correct procedure for disposing of controlled substances.
D. Having a second nurse witness the disposal of the excess medication ensures proper documentation and accountability for controlled substances.

A. Propranolol B. Pantoprazole C. Lovastatin D. Morphine

Correct Answer is A

Explanation

A. Propranolol is a beta-blocker used to control blood pressure and heart rate. However, the nurse has a hold order for propranolol if the apical pulse (heart rate) is less than 50 beats per minute. The nurse documented a heart rate of 42 bpm at 0815, which falls below the hold parameter for propranolol. Administering propranolol in this case could worsen the client's bradycardia (slow heart rate) and therefore requires an incident report.
B. Pantoprazole is a proton pump inhibitor and doesn't have a direct impact on heart rate within the usual therapeutic range.
C. Lovastatin is a cholesterol medication and wouldn't cause a significant drop in heart rate at this dosage.
D. While morphine can slow the heart rate, it's typically used for pain management and may be necessary for the client's comfort. However, the nurse should monitor the respiratory rate closely due to potential respiratory depression.
E. Cefuroxime is an antibiotic and wouldn't significantly affect heart rate.

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36. A nurse is caring for a client. Exhibits Which of the following findings at 1015 requires further action?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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36. A nurse is caring for a client.
Exhibits
Which of the following findings at 1015 requires further action?