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 B
Explanation
A. "Speech therapist" –
A speech therapist helps clients with swallowing difficulties (dysphagia) and communication impairments but does not focus on activities of daily living (ADLs) like dressing and toileting.
B. "Occupational therapist" –
An occupational therapist assists clients in regaining independence with ADLs, such as dressing, toileting, and bathing, by teaching adaptive techniques and recommending assistive devices.
C. "Physical therapist" –
A physical therapist focuses on improving mobility, strength, and balance but does not specifically address dressing and toileting tasks.
D. "Recreational therapist" –
A recreational therapist works on improving the client’s quality of life through leisure activities and social engagement, not basic self-care tasks.
Correct Answer is C
Explanation
A. Inform the client they cannot refuse the surgery once the consent form has been signed. A client has the right to refuse treatment at any time, even after signing a consent form.
B. Explain the risks of the surgery to the client. The provider is responsible for explaining the risks, benefits, and alternatives of the procedure. The nurse's role is to witness consent and ensure the client understands.
C. Ensure the client has advance directives on file. Since the client has a serious, life-threatening illness (stage 4 cancer) and is undergoing surgery, it is important to verify whether they have advance directives, such as a living will or durable power of attorney for healthcare. These documents ensure that their wishes regarding medical treatment are followed.
D. Ask the client if they wish to be resuscitated in the event they stop breathing. While this is an important conversation, it is typically initiated by the provider. The nurse should confirm whether the client has a Do Not Resuscitate (DNR) order or advance directives in place.
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