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. Applying restraints over clothing helps to prevent direct skin contact, which can reduce the risk of skin irritation, abrasions, and pressure sores that might occur from prolonged contact with the restraint material. It also serves as a layer of padding, offering additional comfort for the patient. Moreover, clothing can act as a barrier against potential constriction of blood flow or nerve compression.
B. Two fingers should fit between the restraint and the client's body and not four fingers. This helps prevent excessive tightness, which can lead to restricted circulation and skin breakdown. This action promotes client safety and comfort.
C. Checking the client's skin integrity should be done done more frequently than the four hours to assess for any skin damage or irritation.
D. Tying the belt restraint to the side rail of the bed may pose a safety risk, as it could restrict the client's movement and lead to injury or discomfort. The belt restraint should be anchored to an immobile part of the bed.
Correct Answer is D
Explanation
A. Rubella (German measles) is caused by a different virus and does not pose a risk of transmission to a client with herpes zoster.
B. Tuberculosis is caused by a bacterium and does not pose a risk of transmission to a client with herpes zoster.
C. HIV infection does not pose a risk of transmission to a client with herpes zoster unless there are other infectious diseases present.
D. Herpes zoster (shingles) is caused by the varicella-zoster virus, which is the same virus that causes chickenpox (varicella). A client who has had varicella is not at risk of contracting herpes zoster from a roommate with active shingles. Therefore, this roommate is appropriate.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.