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 .

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale
Contractures, or the shortening and hardening of muscles, tendons, or other tissue, can be a complication of burns. However, they are not typically the primary risk for a patient with burns on the head, neck, and chest.
Choice B rationale
While fluid imbalance can occur with any burn due to loss of fluid from the damaged skin, it is not typically the primary risk for a patient with burns on the head, neck, and chest.
Choice C rationale
Airway obstruction is a primary risk for a patient with burns on the head, neck, and chest. Swelling from the burns can lead to obstruction of the airway, making it difficult for the patient to breathe.
Choice D rationale
While infection is a risk with any burn, it is not typically the primary risk for a patient with burns on the head, neck, and chest. The primary risk is airway obstruction due to swelling from the burns.

A. Attached to the foot of the bed. B. Below the level of the patient’s chest. C. Along the side of the patient’s knee. D. At the level of the patient’s clavicle.

Correct Answer is B

Explanation

Choice A rationale
Attaching the chest tube system to the foot of the bed is not recommended. This position could potentially cause the system to tip over or become disconnected, which could lead to complications such as pneumothorax or hemothorax.
Choice B rationale
The chest tube system should be placed below the level of the patient’s chest. This allows for gravity-assisted drainage of air and fluid from the thoracic cavity, which is crucial for the patient’s recovery. The system works on a water seal that prevents air or fluid from entering the pleural space. Placing the system below the chest level ensures that the water seal is maintained, preventing backflow of fluid or air into the pleural space.
Choice C rationale
Placing the system along the side of the patient’s knee is not appropriate. This position does not facilitate effective drainage of air and fluid from the thoracic cavity. It could also lead to discomfort and potential dislodgement of the system.
Choice D rationale
Placing the system at the level of the patient’s clavicle is not recommended. This position is too high and could disrupt the water seal, leading to ineffective drainage and potential complications.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with partial-thickness and full-thickness burns on the head, neck, and chest. What is the primary risk to the client?

Correct Answer is C

Explanation

A patient arrives at the emergency department with a stab wound to the chest. The healthcare provider places two chest tubes to drain air and blood from the patient’s thoracic cavity. Where should the nurse place the system?

Correct Answer is B

Explanation

The nurse is about to administer 1 liter (1000 mL) of 0.9% NS over 2 hours intravenously to a patient in shock. What rate should the nurse set on the infusion pump?

A patient with aplastic anemia is scheduled to receive an injection of erythropoietin (Epogen). The patient inquires about the purpose of the injection. How should the nurse respond?

A nurse is educating a patient newly diagnosed with iron deficiency anemia. Which of the following would be a component of the education?

A patient has severe trauma from an automobile accident. The nurse is checking the gastric pH and is administering Protonix 40 mg IV piggyback two times a day as ordered. This is prophylactic to prevent which of the following?

A nurse is educating a client newly diagnosed with hepatitis C. Which statement from the nurse best describes how the virus is transmitted?

The nurse is caring for an 85-year-old patient with septic shock. What should the nurse consider when repositioning this patient?