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. Increased hunger: Dysphagia is not typically associated with increased hunger.
B. Garbled voice: Difficulty swallowing (dysphagia) can result in a garbled or hoarse voice due to food or liquid entering the airway.
C. Sneezing: While sneezing is not typically associated with dysphagia, it can be a response to irritants in the nasal passages.
D. Rapid chewing: Rapid chewing is not necessarily indicative of dysphagia and may occur for various reasons, such as habit or anxiety.
Correct Answer is ["B","C","E"]
Explanation
A. Squeezing the client's finger until a blood drop forms can result in hemolysis and inaccurate results; instead, gentle milking or massaging of the finger is recommended.
B. Applying clean gloves is necessary to maintain infection control practices.
C. Pricking the side of the client's finger is the appropriate technique for obtaining a capillary blood specimen.
D. Elevating the client's hand above the level of the heart is not necessary and may impede blood flow.
E. Cleansing the client's finger with an iodine swab helps to disinfect the area prior to obtaining the blood specimen.
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