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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 10/min

Blood pressure 98/58 mm Hg

S1, S2, no murmur, bradycardia

decreased respiratory effort

equal chest expansion, bilateral crackles

somnolent

oropharynx clear,

mucous membranes moist

pinpoint pupils

Respiratory rate 10/min

Blood pressure 98/58 mm Hg

Heart rate 58/min

Answer and Explanation

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

Decreased respiratory effort, bilateral crackles: Reduced respiratory effort following opioid administration suggests opioid-induced respiratory depression. Crackles may indicate early airway compromise due to poor ventilation or fluid accumulation, requiring immediate intervention to support breathing.
Somnolent: Somnolence beyond expected postoperative drowsiness, especially in combination with other signs of opioid overdose, indicates central nervous system depression. The client is difficult to arouse, raising concern for airway and breathing compromise.
Pinpoint pupils: Pinpoint pupils are a hallmark sign of opioid toxicity. In the setting of recent morphine administration and accompanying respiratory depression, this finding confirms that opioid overdose is likely occurring and must be treated promptly.
Respiratory rate 10/min: A respiratory rate under 12 breaths per minute following opioid administration is a major red flag for opioid-induced respiratory depression. Immediate action is needed to prevent further decline in respiratory status, including potential use of naloxone.
Blood pressure 98/58 mm Hg: The client’s blood pressure has dropped significantly compared to the earlier reading, suggesting opioid-related hypotension. While not yet critically low, the trend combined with other overdose signs indicates instability needing close monitoring and intervention.
Heart rate 58/min: Although the client is bradycardic, this alone is not the most urgent issue compared to respiratory depression and neurological decline. It should still be monitored closely, but it is less immediately life-threatening than the airway and breathing concerns.
Temperature 37.4° C (99.4° F): This temperature is within normal range and does not require follow-up. There are no indications of infection or thermoregulatory issues based on the current temperature.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. "I'm sorry to hear that, but I know the dialysis will make you feel better.": This response dismisses the client’s feelings and moves too quickly to reassurance without first exploring the client’s perspective. It can make the client feel unheard and pressured to accept the treatment.

B. "What are your concerns about the dialysis treatments?": This response encourages open communication by inviting the client to express their fears, concerns, or misunderstandings. It shows respect for the client's autonomy and fosters a therapeutic relationship built on trust and understanding.

C. "Do you think your doctor would have recommended dialysis if you didn't need it?": This shifts focus away from the client’s feelings and places undue emphasis on the authority of the provider. It may make the client feel invalidated or coerced rather than supported in making an informed decision.

D. "Most people do get tired of dialysis treatments after a while.": This statement reinforces negative feelings about dialysis and can increase the client’s anxiety or resistance toward the treatment rather than helping them work through their concerns in a constructive manner.

A. Repeat quantitative B-hCG level B. Methotrexate IM C. Blood typing D. Cervical cerclage E. Transvaginal ultrasound

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

• Repeat quantitative B-hCG level: Monitoring the trend of quantitative beta-hCG levels is crucial in suspected ectopic pregnancy. Falling or plateauing hCG levels confirm the diagnosis and guide the management plan, especially if methotrexate is administered or surgical intervention is considered.

• Methotrexate IM: Methotrexate is an anticipated prescription for the medical management of a stable ectopic pregnancy. It works by stopping the growth of rapidly dividing cells and is appropriate when the client is hemodynamically stable and the ectopic pregnancy is unruptured.

• Blood typing: Blood typing is essential to determine Rh factor status. If the client is Rh-negative, Rh immune globulin should be administered to prevent isoimmunization, which could impact future pregnancies. This is a standard part of the care plan for any pregnancy loss or threatened pregnancy complication.

• Transvaginal ultrasound: A transvaginal ultrasound is needed to confirm the location of the pregnancy. In ectopic pregnancies, it helps visualize the presence or absence of an intrauterine gestational sac and may directly identify ectopic implantation, such as in the fallopian tube.

• Cervical cerclage: Cervical cerclage is contraindicated in this case. It is used to prevent preterm birth in clients with cervical insufficiency but is not appropriate in a non-viable pregnancy or suspected ectopic pregnancy. Placing a cerclage could worsen the clinical situation and delay necessary treatment.

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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 10/min Blood pressure 98/58 mm Hg

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who states, "I don't want to start dialysis treatments." Which of the following responses should the nurse make?

Correct Answer is B

Explanation

The nurse has reviewed the Graphic Record and Diagnostic Results at 1030. The nurse is collaborating with another nurse about the client's plan of care. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

A nurse at a provider's office is caring for a client. Select the 3 findings that require immediate follow-up.

A nurse is reinforcing teaching with a client about advance directives and a health care proxy. Which of the following client statements indicates an understanding of the teaching?

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A nurse is assisting with the care of a client who is verbalizing their desire for natural family planning as a method of contraception. Which of the following responses should the nurse make?

A nurse is collecting data from a client who has acute pancreatitis. Which of the following findings should the nurse expect?

The nurse has reviewed the Nurses' Notes and Vital Signs at 1200. Which of the following 2 findings indicate that the client is experiencing a complication after the procedure?

A nurse is reinforcing teaching about foot care to a client who has diabetes mellitus. Which of the following information should the nurse include in the teaching?

A nurse is documenting client care in the nurses' notes and notices that a space was left blank. Which of the following actions should the nurse take?