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 B
Explanation
A. Dismissing the employee's concerns by stating there has been too much complaining is not empathetic or supportive.
B. This response acknowledges the employee's feelings and opens the door for further discussion about their concerns, allowing the charge nurse to address them.
C. Suggesting filing a formal complaint with Human Resources may escalate the situation unnecessarily and should not be the initial response.
D. While expressing optimism about the situation may be well-intentioned, it does not address the employee's concerns or offer support.
Correct Answer is A
Explanation
A. This response acknowledges the client's concerns and opens the conversation for the nurse to address the client's specific needs and preferences, which is crucial in end-of-life care.
B. While pain management is important, addressing the client's concerns about the end-of-life care and their expectations should be the priority.
C. While family visits are significant, addressing the client's immediate concerns about their care takes precedence.
D. Spiritual support is important but may not address the client's immediate concerns about the care they will receive as death approaches.
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