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A nurse is caring for a client on the medical surgical unit.

Click to highlight the findings at 1630 that require immediate follow-up. To deselect a finding, click on the finding again.

Body System

Findings

Cardiovascular

S1,S2, no murmur, bradycardia

Respiratory

decreased respiratory effort, equal chest expansion, bilateral crackles

Neurologic

somnolent

Head, Ears, Eyes, Nose, and Throat(HEENT)

oropharynx clear, mucous membranes moist, pinpoint pupils

Vital Signs

Temperature 37.4°C (99.4°F)

Heart rate 58/min

Respiratory rate 10min

Blood pressure 98/58 mm Hg

S1,S2, no murmur

decreased respiratory effort

bilateral crackles

somnolent

pinpoint pupils

Temperature 37.4°C (99.4°F)

Respiratory rate 10min

Blood pressure 98/58 mm Hg

Answer and Explanation

The Correct Answer is ["B","C","D","E","G","H"]

Recognizing opioid-induced respiratory depression after administration of IV morphine in a postoperative client is important. Morphine is an opioid analgesic that can depress the central nervous system, leading to decreased respiratory drive, sedation, hypotension, and pinpoint pupils. The client’s worsening drowsiness, slow respirations, and decreased responsiveness shortly after receiving morphine strongly suggest opioid toxicity. Immediate identification is critical because untreated respiratory depression can rapidly progress to hypoxia, respiratory arrest, and cardiac arrest.

Rationale for correct findings:

• Respiratory; decreased respiratory effort, equal chest expansion, bilateral crackles: Decreased respiratory effort is the most urgent sign of opioid-induced respiratory depression. Opioids suppress the respiratory center in the brainstem, causing slow and shallow breathing that reduces oxygen exchange. Bilateral crackles may also suggest retained secretions or fluid accumulation due to poor ventilation. Respiratory compromise is the highest priority.

• Neurologic; somnolent: Somnolence indicates excessive CNS depression and reduced responsiveness, which commonly occurs with opioid overdose or excessive opioid effect. A client who is slow to arouse may rapidly progress to unresponsiveness if respiratory depression worsens. Increasing sedation after morphine administration is a major warning sign. This requires urgent reassessment and likely reversal intervention.

• HEENT; pinpoint pupils: Pinpoint pupils (miosis) are a classic sign of opioid toxicity and strongly support the suspicion of morphine overdose or excessive opioid response. When seen with respiratory depression and somnolence, this finding is especially concerning. It helps confirm that the symptoms are medication-related rather than another postoperative complication. Immediate intervention is needed.

• Vital Signs; Respiratory rate 10/min: A respiratory rate of 10/min is below normal and indicates significant respiratory depression. Opioid administration can suppress respiratory drive, leading to hypoventilation and poor oxygenation. This is one of the earliest and most dangerous indicators of opioid toxicity. Prompt action such as naloxone administration may be required.

• Vital Signs; Blood pressure 98/58 mm Hg: Morphine can cause vasodilation and hypotension, especially when combined with sedation and decreased respiratory effort. A drop in blood pressure from baseline suggests worsening hemodynamic status and possible poor tissue perfusion. In combination with bradycardia and CNS depression, this increases concern for opioid excess.

Rationale for incorrect findings:

• Cardiovascular; S1, S2, no murmur: The normal heart sounds without murmur indicate no acute structural cardiac issue. In this situation, respiratory compromise takes priority over mild bradycardia. Therefore, this finding is monitored but not the most immediate concern.

• Vital Signs: Temperature 37.4°C (99.4°F): This temperature is within normal postoperative range and does not indicate fever or infection. There is no evidence of sepsis or acute inflammatory complications. Compared with respiratory depression and decreased consciousness, temperature is not an urgent concern.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A long leg cast is used to immobilize fractures and promote bone healing, but it can also lead to complications such as compartment syndrome, impaired circulation, and nerve compression. After cast application, ongoing assessment of neurovascular status is essential to detect early signs of compromised perfusion. Pain that worsens rather than improves is a critical warning sign of potential complications requiring immediate intervention. Nurses must differentiate expected discomfort from abnormal findings that indicate tissue ischemia.

Rationale:
A. Increasing pain in the affected extremity is a hallmark early sign of compartment syndrome or impaired circulation under the cast. This type of pain is often severe, unrelieved by analgesics, and may worsen with movement. It indicates rising pressure within the muscle compartments that can compromise blood flow and tissue viability, requiring immediate provider notification.

B. Itching beneath the cast is a common and expected finding during the healing process. It results from skin dryness and tissue regeneration under immobilization. Although uncomfortable, it does not indicate neurovascular compromise and can be managed with safe comfort measures.

C. Warm toes indicate adequate peripheral perfusion and are a normal finding after cast application. This suggests that arterial blood flow to the distal extremity is intact. It is a reassuring sign rather than an abnormal one that requires reporting.

D. Capillary refill of 3 seconds is slightly delayed but may still be within acceptable limits depending on baseline and clinical context. However, it is less urgent than escalating pain. It should be monitored closely, but increasing pain is a more critical early indicator of compromised circulation that requires immediate attention.

A. The client develops lanugo. B. The client's blood pressure is 88/59 mm Hg. C. The client's heart rate is 54/min. D. The client resumes menstruation.

Correct Answer is D

Explanation

Anorexia nervosa is a serious psychiatric condition associated with severe malnutrition, endocrine dysfunction, and multi-system complications. Treatment focuses on restoring nutritional status, stabilizing vital signs, and correcting hormonal imbalances. As recovery progresses, physiological functions suppressed by starvation begin to normalize. One key indicator of effective treatment is the return of normal reproductive function.

Rationale:
A. The development of lanugo is a sign of chronic starvation and the body’s attempt to conserve heat in response to fat loss. It indicates worsening or ongoing malnutrition rather than improvement. Therefore, its presence reflects an untreated or poorly managed condition rather than a treatment outcome.

B. A blood pressure of 88/59 mm Hg indicates hypotension, which is commonly seen in malnourished clients due to reduced cardiac output and fluid volume depletion. This is not an expected outcome of treatment, as effective management should result in stabilization and improvement of blood pressure toward normal ranges.

C. A heart rate of 54/min represents bradycardia, which is a common physiologic response to starvation and decreased metabolic demand. It may be present during illness, but it is not a desired treatment outcome. Successful treatment would lead to normalization of heart rate as nutritional status improves.

D. Resumption of menstruation is an expected and positive outcome of treatment in anorexia nervosa. Restoration of adequate body fat and hormonal balance allows normalization of the hypothalamic-pituitary-ovarian axis. This indicates improved nutritional status and recovery of endocrine function, making it a key marker of effective therapy.

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Body System	Findings
Cardiovascular	S1,S2, no murmur, bradycardia
Respiratory	decreased respiratory effort, equal chest expansion, bilateral crackles
Neurologic	somnolent
Head, Ears, Eyes, Nose, and Throat(HEENT)	oropharynx clear, mucous membranes moist, pinpoint pupils
Vital Signs	Temperature 37.4°C (99.4°F) Heart rate 58/min Respiratory rate 10min Blood pressure 98/58 mm Hg

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has a long leg cast that was applied 2 days ago. Which of the following findings should the nurse report to the provider?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse identify as an expected outcome of treatment?

Correct Answer is D

Explanation

A nurse is reinforcing teaching about home management with the partner of a client who has dementia. Which of the following instructions should the nurse include in the teaching?

A nurse is providing a client with IV fluids and finds that the IV pump screen is malfunctioning. Which of the following actions should the nurse take?

A nurse is reinforcing teaching for a client who has a new ascending colostomy. Which of the following comments by the client indicates an understanding of the teaching?

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following actions should the nurse take to promote progression toward independence and mobility for the client?

A nurse is monitoring a young adult client for risk-taking behavior. Which of the following statements by the client indicates they are limiting their risk-taking behavior?

A nurse is reviewing the laboratory results for a client who is receiving digoxin and notes a decreased potassium level. The nurse should monitor the client for which of the following adverse effects?

A nurse is reinforcing teaching about the importance of pain management with a client who is postoperative. The client states, "I'm pretty tough and can take a lot of pain." Which of the following responses should the nurse make?

A home health nurse is completing a home safety visit for a client who had a cerebrovascular accident (CVA). Which of the following actions should the nurse take?