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 B
Explanation
Choice A rationale
While erythropoietin (Epogen) can help improve symptoms of anemia, such as fatigue, it does not directly increase energy levels.
Choice B rationale
Erythropoietin (Epogen) stimulates the body to produce more of its own red blood cells. This is its primary function and the reason it is used in the treatment of anemia.
Choice C rationale
Erythropoietin (Epogen) does not work like a blood transfusion. While both can increase the number of red blood cells, erythropoietin stimulates the body to produce more of its own red blood cells, while a blood transfusion involves adding red blood cells from a donor.
Choice D rationale
Erythropoietin (Epogen) does not inhibit proteins that attack blood cells. It works by stimulating the production of more red blood cells.
Correct Answer is B
Explanation
Choice B rationale
A respiratory rate of 20 breaths per minute is within the normal range for an adult, indicating that the patient’s respiratory status is stable. This would be an important indicator of the effectiveness of nursing care in a patient admitted with a lower respiratory infection.
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