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. Using a 10-mL syringe filled with cleansing solution provides appropriate pressure for effective wound irrigation.
B. Drying the wound bed with gauze squares is not typically recommended as it may disrupt healing and cause trauma to the wound.
C. Cleansing the wound with cotton balls may leave fibers behind and is not the most effective method of wound irrigation.
D. Holding the syringe tip 2.5 cm (1 in) above the wound is incorrect; the tip should be inserted into the wound to facilitate thorough irrigation.
Correct Answer is D
Explanation
A. Providing teaching without expecting the client to respond does not facilitate communication or ensure the client understands the information. The goal is to enhance communication, not to bypass it.
B. Speaking with a loud voice is unnecessary and can be counterproductive. Expressive aphasia affects the client’s ability to express themselves, not their hearing. Speaking loudly will not improve the client's ability to understand or communicate.
C. Avoiding facial gestures is not recommended. Non-verbal communication, such as facial expressions and gestures, can be valuable in helping the client understand the information being conveyed.
D. Determining the client’s ability to use a communication board is the most appropriate action. A communication board can help the client express their needs and understand instructions more effectively, making it a valuable tool for reinforcing teaching in clients with expressive aphasia.
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.