A nurse is caring for a client who is postoperative and is receiving opioid analgesics. Which of the following findings should the nurse report to the provider?
Oral temperature 37.4° C (99.3° F)
BP 130/84 mm Hg
Heart rate 88/min
Respiratory rate 10/min
The Correct Answer is D
A. Oral temperature 37.4°C (99.3°F): This is a low-grade fever and is generally not concerning unless it increases or persists. It could be related to the body’s response to surgery but does not require immediate reporting to the provider.
B. BP 130/84 mm Hg: This is a normal blood pressure for most adults and does not indicate an issue. There is no immediate concern for the nurse to report this to the provider.
C. Heart rate 88/min: A heart rate of 88 beats per minute is within normal range for an adult and does not require reporting to the provider.
D. Respiratory rate 10/min: A respiratory rate of 10/min is significantly below the normal range for an adult (12-20 breaths per minute) and could indicate respiratory depression, a common side effect of opioid analgesics. This is a serious finding and should be reported to the provider immediately for further evaluation and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Let me clarify that you want the medication given gid, correct?": When receiving a telephone prescription, it is essential to clarify any unclear aspects of the order, such as the dosage frequency. This ensures that the prescription is accurately understood and implemented and helps prevent medication errors.
B. "Will you please spell the name of that medication for me?": Although confirming the medication name is important, it is more critical to clarify the specific directions for administering the medication, such as the frequency, rather than spelling.
C. "I will sign my name now and leave a space for you to sign your name.": Offering to leave a space for the provider's signature is standard practice. However, it's not the most critical communication safety check during the verbal order itself.
D. "Let me provide you with the client's medical record number for identification.": While important for ensuring correct patient identification, the nurse should first focus on accurately obtaining the medication prescription and other critical details before providing identification information.
Correct Answer is B
Explanation
A. Make a priority list of information the client should learn: While making a priority list of information is important, it should come after assessing the client's learning needs. This ensures that the most relevant and important information is prioritized.
B. Determine the client's learning needs: The first step in planning teaching is to assess the client’s learning needs. This allows the nurse to tailor the teaching plan to the client’s level of understanding, cultural preferences, and specific concerns related to the central venous access device.
C. Obtain written information to give the client: Written information is helpful but should not be the first step. It is more effective when tailored to the client’s learning needs, which should be assessed first to ensure relevance.
D. Select a visual method to reinforce verbal teaching for the client: Visual methods can be helpful for reinforcing verbal teaching, but this step should follow the assessment of the client’s learning needs. Teaching strategy should align with the client’s preferred learning style.
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