A nurse is assessing a client who has opioid toxicity. Which of the following findings should the nurse expect?

The correct answer is b.

Choice A: SpO2 95%

The normal range for SpO2, or peripheral capillary oxygen saturation, is typically between 95% and 100%. While a SpO2 of 95% is within the normal range, it doesn't necessarily indicate an understanding of vital signs as it's on the lower end of the normal range.

Choice B: Right radial pulse regular 68/min

The normal resting heart rate for adults ranges from 60 to 100 beats per minute. Therefore, a right radial pulse of 68 beats per minute falls within the normal range and indicates an understanding of vital signs.

Choice C: Temp 36°C (96.8°F)

The normal body temperature for a healthy adult can range from 97.8°F (36.5°C) to 99.1°F (37.3°C). Therefore, a body temperature of 36°C (96.8°F) is slightly below the normal range.

Choice D: BP 148/72 mm Hg

The normal range for blood pressure in adults is between 90/60 mmHg and 120/80 mmHg. A blood pressure reading of 148/72 mm Hg is above the normal range for systolic pressure (the top number), indicating high blood pressure (hypertension).

1. Remove protective gown before removing gloves.

When caring for a client with Clostridium Difficile, it is important to follow strict contact precautions to prevent the spread of the bacteria. The nurse should remove the protective gown before removing gloves to avoid contaminating the gown with any bacteria that may be on the gloves. This helps to minimize the risk of spreading the bacteria to other clients or healthcare workers.

1. Shake bed linens before placing them in a linen bag.

Shaking bed linens can cause any bacteria that may be on them to become airborne, increasing the risk of spreading the bacteria to other surfaces. Instead, bed linens should be rolled up and placed directly into a linen bag without shaking them.

1. Use an electronic thermometer to take the client's temperature.

An electronic thermometer is preferred when taking the temperature of a client with Clostridium Difficile because it can be easily disinfected between uses, reducing the risk of spreading the bacteria.

1. Remove protective gloves when leaving the client's room.

Protective gloves should be removed before leaving the client's room to avoid contaminating other surfaces or spreading the bacteria to other clients or healthcare workers.