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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. Place the client in a negative pressure room: Negative pressure rooms are used for airborne diseases like tuberculosis or measles, where pathogens are airborne. VRE is a contact-transmitted infection, not airborne, so a negative pressure room is not necessary.

B. Wear a gown and gloves during client interactions and care: VRE is spread through direct contact with contaminated surfaces or bodily fluids. Wearing a gown and gloves provides the necessary precautions to prevent the spread of the infection through contact transmission.

C. Wear a surgical mask during client interactions and care: A surgical mask is primarily used for droplet precautions (e.g., influenza), not for contact precautions like VRE. A mask is not necessary unless the client has a respiratory infection or if there is a risk of splashing bodily fluids.

D. Place the client in a room with high-efficiency particulate air (HEPA) filtration for incoming air: HEPA filtration is used for airborne infections such as tuberculosis. Since VRE is not an airborne pathogen, this measure is unnecessary for preventing the spread of VRE.

A. Administer the tablet to the client with applesauce. B. Position the client at a 45 angle C. Crush the tablet and mix it in pudding for the client. D. Instruct the client to tilt their head back when swallowing

Correct Answer is A

Explanation

A. Administer the tablet to the client with applesauce: Administering the tablet with a small amount of soft food like applesauce can help facilitate swallowing without altering the integrity of the enteric coating. This method eases the swallowing process while ensuring the medication is delivered properly.

B. Position the client at a 45-degree angle: Clients who have difficulty swallowing should be positioned in an upright 90-degree sitting position, not at 45 degrees, to reduce the risk of aspiration and promote safer swallowing mechanics.

C. Crush the tablet and mix it in pudding for the client: Enteric-coated tablets should never be crushed, as crushing destroys the protective coating designed to prevent the medication from being released in the stomach, potentially causing irritation or reducing drug effectiveness.

D. Instruct the client to tilt their head back when swallowing: Tilting the head back increases the risk of choking and aspiration, especially in clients with swallowing difficulties. It is safer to encourage tucking the chin slightly down when swallowing to help protect the airway.

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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 assisting in the care of a client who is on isolation for an infection with vancomycin-resistant enterococcus (VRE). Which of the following actions should the nurse take to prevent the spread of infection?

Correct Answer is B

Explanation

A nurse is administering an enteric-coated medication to an adult client who has right-sided weakness and is having difficulty swallowing tablet. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is collecting data from a client who is experiencing ketoacidosis. Which of the following manifestations should the nurse expect to find?

A nurse is collecting data from a client about range-of-motion for various joints. Which of the following images should the nurse identity as an example of a ball and socket joint?

A nurse is assisting the guardians of a newborn with the transition to parenthood. Which of the following actions should the nurse take?

A nurse is assisting in the care of a client who is placed in wrist restraints. Which of the following should the nurse recognize as an expected finding?

A nurse is assisting with the development of a staff in-service about hand hygiene. The nurse should include which of the following instructions regarding the use of hand sanitizer?

A nurse on a postpartum unit is reinforcing discharge teaching for a client who had an episiotomy. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is collecting data from a group of clients. Which of the following images indicates a client the nurse should identify as exhibiting clubbing of the fingers?

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.