A nurse is assisting with the care of a client who is postoperative. The Medication Administration Record indicates
Morphine 8 mg subcutaneous every 3 hours PRN for pain. The vital signs are as follows:
- Temperature: 37.5°C (99.5°F)
- Respirations: 10/min
- Pulse oximetry: 87% on room air
The nurse's notes state the client is alert and oriented to person, place, and time, reporting incisional pain of 9 on a scale of 1 to 10. At 0900, Morphine 8 mg was administered subcutaneously as prescribed. The client is now sleeping and is difficult to arouse, with pupils measuring 3 mm, equal and reactive to light.
The Correct Answer is ["The documentation in the client's medical record that requires further action by the nurse is the pulse oximetry reading of 87% on room air."]
Reason: A pulse oximetry reading of 87% indicates the client may be experiencing hypoxemia, which is a low level of oxygen in the blood and can be a serious postoperative complication. This warrants immediate nursing intervention to assess the client's respiratory status and potentially administer supplemental oxygen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Metabolic Acidosis typically results from conditions that increase acid production or decrease acid excretion, not from vomiting.
Choice B reason: Respiratory Acidosis is caused by hypoventilation leading to an accumulation of carbon dioxide, which is not directly related to vomiting.
Choice C reason: Metabolic Alkalosis can occur due to the loss of stomach acids through prolonged vomiting, leading to an excess of bicarbonate in the body fluids.
Choice D reason: Respiratory Alkalosis is usually caused by hyperventilation, not by vomiting.
Correct Answer is A
Explanation
Choice A reason: Ground beef is often included in a soft diet as it can be cooked to a tender consistency that is easy
to chew and swallow.
Choice B reason: Raw vegetables are generally not included in a soft diet because they can be difficult to chew and may pose a risk for individuals with certain digestive or dental issues.
Choice C reason: Fruit with the skin is typically not recommended for a soft diet as the skin can be tough and fibrous,
making it harder to chew and digest.
Choice D reason: High-fiber cereals are usually avoided in a soft diet because they may contain whole grains or nuts
that are hard and could be challenging to chew.
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