A nurse is assisting a postoperative client.
The client is alert and oriented to person, place, and time, and reports incisional pain of 9 on a scale of 1 to 10. Morphine 8 mg was administered subcutaneously as prescribed at 0900.
The client is now sleeping and is difficult to arouse.
Pupils are 3 mm, equal and reactive to light.
Temperature is 37.5 C (99.5°), respirations are 10/min, and pulse oximetry is 87% on room air.
Which documentation in the client’s medical record requires further action by the nurse?
Pupils are 3 mm, equal and reactive to light
Client is sleeping and is difficult to arouse
Respirations are 10/min
Pulse oximetry is 87% on room air .
The Correct Answer is D
Choice A rationale
Pupils being 3 mm, equal and reactive to light is a normal finding and does not require further action.
Choice B rationale
The client being difficult to arouse could be a side effect of the morphine. However, this is not as immediately concerning as a low oxygen saturation.
Choice C rationale
Respirations being 10/min could be a side effect of the morphine. However, this is not as immediately concerning as a low oxygen saturation.
Choice D rationale
Pulse oximetry reading of 87% on room air is concerning. Normal pulse oximetry readings are typically between 95% and 100%. A reading of 87% indicates the client is not getting enough oxygen, which requires immediate action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["15"]
Explanation
Step 1 is to determine the amount of clindamycin palmitate in each mL of the oral suspension. This is done by dividing the total amount of clindamycin palmitate in 5 mL by 5. So, 75 mg ÷ 5 mL = 15 mg/mL.
Step 2 is to calculate the volume of oral suspension needed to deliver 225 mg of clindamycin palmitate. This is done by dividing the desired dose by the amount of clindamycin palmitate per mL. So, 225 mg ÷ 15 mg/mL = 15 mL.
Therefore, the nurse should administer 15 mL of clindamycin palmitate oral suspension.
Correct Answer is A
Explanation
Choice A rationale
Medicate the client 30 minutes before the procedure. This is the correct action. Administering pain medication 30 minutes before the procedure allows the medication to take effect and provides pain control during the procedure.
Choice B rationale
Reassure the client that the procedure is not painful. This is not accurate. Debridement and hydrotherapy can be painful, so it’s important to manage the client’s pain effectively.
Choice C rationale
Utilize meditation and imagery. While these techniques can be helpful adjuncts to pain management, they should not replace pharmacological pain management in this situation.
Choice D rationale
Administer pain medication around the clock. While it’s important to manage pain effectively, this does not specifically address the client’s needs during the hydrotherapy and debridement procedure.
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