A nurse is caring for a client who is postoperative.
Click to highlight the documentation in the client's medical record that requires further action by the nurse. To deselect documentation, click on the documentation again.
Temperature 37.5° C (99.5° F)
Client is difficult to arouse.
Respiratory rate 10/min
Pulse oximetry 88% on room air (95% to 100%)
Pupils are 3 mm, equal, and reactive to light.
Blood pressure 99/46 mm Hg
Heart rate 61/min
Client is difficult to arouse
Respiratory rate 10/min
Pulse oximetry 88% on room air (95% to 100%)
Blood pressure 99/46 mm Hg
The Correct Answer is ["A","B","C"]
Client is difficult to arouse – This is concerning and may indicate opioid overdose or sedation due to the recent administration of morphine. The nurse should assess the client's level of consciousness closely and consider reversal of the opioid (naloxone) if the client's level of sedation is excessive.
Respiratory rate 10/min – This is below the normal respiratory rate (12–20 breaths/min) and could indicate respiratory depression, a common side effect of opioids like morphine. Close monitoring and possible intervention are required.
Pulse oximetry 88% on room air (95% to 100%) – The oxygen saturation is low, which could indicate hypoxemia. The nurse should administer supplemental oxygen and notify the provider.
Other Findings:
Pupils are 3 mm, equal, and reactive to light – This is a normal finding and not concerning for opioid overdose.
Blood pressure 99/46 mm Hg – This is slightly lower than normal but not critically low, considering the client's condition. Morphine can cause hypotension, especially in older adults or hypovolemic clients.
Heart rate 61/min – This is within a normal range for some postoperative patients, especially in a restful state.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Rhythmic respirations." Normal, rhythmic breathing is not typically associated with pain. Pain may cause labored, irregular, or rapid breathing.
B. "Absent cry." The FLACC scale assesses crying as an indicator of pain. However, an absent cry does not suggest pain. A strong, continuous cry or moaning may indicate discomfort.
C. "Resisting care." Clients with pain often resist movement, care, or interventions due to discomfort or distress. This is a key indicator of pain in the FLACC scale (Activity or Consolability sections).
D. "Relaxed posturing." A relaxed posture suggests comfort, while pain often leads to rigid or tense positioning.
Correct Answer is ["A","B","C","D"]
Explanation
Cardiopulmonary:
Encourage deep-breathing exercises.
Check for pain.
Rationale:
Encouraging deep-breathing exercises helps improve oxygenation and prevent complications such as atelectasis, especially since the client's oxygen saturation initially dropped but improved with deep breathing.
Checking for pain is essential as the client has been prescribed PRN morphine for pain management.
"Inform client to achieve two to four breaths per session when using an incentive spirometer" is not selected because while incentive spirometer use is encouraged, the prescribed plan instructs use every hour while awake rather than focusing on a specific number of breaths per session.
Gastrointestinal:
Promote intake of oral fluids.
Apply barrier ointment after bowel movements.
Rationale:
Promoting oral fluid intake helps prevent dehydration and supports bowel function, especially since the client reports multiple loose stools and nausea/vomiting.
Applying barrier ointment after bowel movements helps protect the skin from irritation and breakdown due to frequent loose stools.
"Encourage the client to increase fiber in their diet" is not selected because fiber intake is usually increased for constipation, whereas in this case, the client has diarrhea, and fiber could worsen symptoms.
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