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. Prime the IV tubing with lactated Ringer's. Blood products should only be primed with 0.9% sodium chloride (normal saline) because other solutions (e.g., lactated Ringer's or dextrose solutions) can cause hemolysis.
B. Use a 24-gauge IV catheter for the transfusion. A 24-gauge catheter is too small for a blood transfusion and may cause hemolysis or slow infusion. A large-bore catheter (18–20 gauge) is recommended for optimal flow.
C. Ensure that the IV tubing has an in-line filter. An in-line filter helps remove clots and debris, reducing the risk of transfusion reactions.
D. Prepare to change the tubing at least every 2 hr. Blood tubing should typically be changed after 4 hours or after two units of blood, whichever comes first, to prevent bacterial contamination.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
- Oxygen Saturation (90%) – This is a drop from the initial 95% and indicates potential hypoxia. The increased respiratory rate and depth may be compensatory mechanisms.
- Behavioral Findings ("I feel like something is wrong.") – Clients experiencing early signs of deterioration often report a sense of unease. This, combined with agitation, could indicate worsening hypovolemia or hypoxia.
The client's low hemoglobin (8.3 g/dL) and hematocrit (32%) suggest significant blood loss during surgery, which could contribute to hypoxia and hemodynamic instability. Immediate follow-up is needed to assess for potential ongoing bleeding, oxygenation issues, or early signs of shock.
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