A nurse is caring for a client who is postoperative.
Medication Administration Record
0830:
Morphine 10 mg subcutaneous every 3 hr PRN pain
What documentation in the client's medical record requires further action by the nurse.
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
Correct Answer : B,C,D
A. A temperature of 37.5° C (99.5° F) is slightly elevated but can be expected postoperatively and does not typically require immediate intervention.
B. The client being difficult to arouse is concerning following opioid administration, as it may indicate over-sedation or the onset of respiratory depression. This requires immediate nursing action.
C. A respiratory rate of 10/min is low and can be a sign of opioid-induced respiratory depression, especially when combined with difficulty arousing the client. This is a critical value that
necessitates prompt nursing assessment and intervention.
D. Pulse oximetry of 88% on room air is below the normal range and indicates hypoxemia. This is a serious finding that requires immediate action to improve the client's oxygenation.
E. Pupils that are 3 mm, equal, and reactive to light, along with a blood pressure of 99/46 mm Hg, while on the lower side, are not as immediately concerning as the respiratory rate and level of consciousness.
F. A heart rate of 61/min is within normal limits and does not typically require intervention unless there are other signs of hemodynamic instability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This response acknowledges the client's decision and expresses concern for their well-being and the potential impact on their loved ones. It also opens the door for the client to discuss their decision-making process and receive support in communicating their decision to others.
B. This response may be perceived as judgmental or dismissive of the client's autonomy and decision-making capacity. It does not provide support or address the client's emotional or psychosocial needs.
C. Delaying the discussion may leave the client feeling unsupported or uncertain about their
decision. It's important to address the client's concerns and provide support in a timely manner.
D. This response minimizes the client's concerns and does not offer support or encouragement for discussing their decision with loved ones. It may also convey a lack of empathy or
understanding of the client's situation.
Correct Answer is D
Explanation
A. This response may be perceived as judgmental and could potentially worsen the client's anxiety or stress.
B. While involving the doctor may eventually be necessary, it's important for the nurse to first acknowledge and respect the client's decision.
C. Asking "why" may seem confrontational and might not foster a therapeutic relationship. It's important to respect the client's autonomy and decision-making process.
D. This response acknowledges the client's decision and demonstrates understanding and acceptance, which can help build trust and rapport between the nurse and the client.
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