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. The hypoglossal nerve is tested by checking for tongue deviation.
B. This action tests the facial nerve
C. This action tests the trigeminal nerve
D. This action tests the spinal accessory nerve
Correct Answer is A
Explanation
A. Nail polish can interfere with the accuracy of pulse oximetry readings by absorbing or
reflecting light, leading to falsely low oxygen saturation readings. It's essential to remove nail polish or acrylic nails from the finger used for pulse oximetry to obtain accurate results.
B. While an elevated hemoglobin level may affect the oxygen-carrying capacity of the blood, it does not directly influence the accuracy of pulse oximetry readings.
C. Fever may affect oxygen saturation levels indirectly by increasing metabolic demand or
respiratory rate, but it does not directly interfere with the accuracy of pulse oximetry readings.
D. Wearing a ring does not typically interfere with pulse oximetry readings unless the ring is very tight and impairs blood flow to the finger. However, nail polish is a more significant
concern for accurate readings.
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