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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Inject 15 units of air into the regular insulin vial: After injecting air into the NPH vial without drawing up the medication, the next step is to inject air into the regular insulin vial. This maintains the correct order and prevents contamination of the regular insulin with the cloudy NPH insulin.
B. Withdraw 10 units of NPH insulin: NPH insulin should not be withdrawn first because it is cloudy and could contaminate the regular insulin if mixed incorrectly. Regular insulin, which is clear, should always be drawn up before NPH when mixing in the same syringe.
C. Verify the dosage with another nurse: Verifying insulin doses with another nurse is necessary but is typically done after the insulin is prepared and drawn up. At this stage, the immediate step is to complete proper air injection into both vials before drawing any insulin.
D. Place the cap over the needle: Recapping needles increases the risk of accidental needlestick injuries and should be avoided unless absolutely necessary. There is no need to recap at this stage in the insulin preparation process.
Correct Answer is D
Explanation
A. A toddler who has periorbital cellulitis and has an axillary temperature of 37.6°C (99.7°F): A mild temperature in the context of periorbital cellulitis is expected and not an immediate emergency. Although periorbital cellulitis can be serious, this temperature alone does not demand immediate action over other critical symptoms.
B. An adolescent who has influenza and reports a headache of 6 on a scale of 0 to 10: A headache with influenza is common and requires monitoring, but unless there are signs of severe neurological involvement, it is not the highest priority compared to potential circulatory compromise.
C. An infant who had a pyloromyotomy 12 hr ago and spit up after the last feeding: Mild vomiting or spitting up is common following a pyloromyotomy and is not unusual within the first 24 hours postoperatively. It generally does not require immediate intervention unless persistent or worsening.
D. A child who had a cast placed 4 hr ago and reports numbness in the affected extremity: Numbness may indicate impaired circulation or nerve compression, a sign of possible compartment syndrome. This is a surgical emergency that can result in permanent damage if not promptly assessed and treated.
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