A nurse is caring for a postoperative male client in the surgical unit. The following exhibits are available for review
Click to highlight the documentation in the client's medical record that requires further action by the nurse. To deselect documentation, click on the documentation again. Select all that apply
Respiratory rate 10/min
Pulse oximetry 88% on room air
Blood pressure 99/46 mm Hg
Morphine 10 mg administered subcutaneously
Correct Answer : A,B,D
Choice A rationale: The client’s respiratory rate of 10/min is below the normal range (12-20 breaths per minute). This suggests respiratory depression, which can be caused by opioid medications like morphine.
Choice B rationale: The client’s pulse oximetry reading of 88% on room air is lower than the normal range (95%-100%). This indicates hypoxemia, which may be due to respiratory depression from the morphine.
Choice C rationale: Although the blood pressure of 99/46 mm Hg is low, it might be acceptable for this client postoperatively. However, it does not require immediate intervention compared to the other choices.
Choice D rationale: The administration of morphine 10 mg subcutaneously needs further action because the client is showing signs of opioid overdose (e.g., respiratory depression, hypoxemia). This necessitates reassessment and potential adjustment of the medication dosage or frequency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
"Let's talk about what you're thinking.”. This response encourages open communication and allows the nurse to address any concerns or confusion the client may have. It shows empathy and helps build a therapeutic relationship.
Choice B rationale
"Is this something you think you can do?" While this question assesses the client's confidence, it may not address underlying concerns that cause distraction. The focus should be on understanding the client's thoughts and feelings first.
Choice C rationale
"Are you feeling okay?" This question is more about physical well-being, which may not be the reason for the client's distraction. It's better to address emotional or cognitive concerns related to the teaching session.
Choice D rationale
"Do you need more time to absorb this information?" While offering more time can be helpful, it doesn't directly address the client's distraction. Engaging the client in a conversation about their thoughts can be more effective in understanding their needs.
Correct Answer is C
Explanation
Choice A rationale
Telling the client's partner to discuss their feelings when not feeling overwhelmed is dismissive. It does not address their current emotional state or offer support. This response can make the partner feel unheard and may not provide immediate relief or understanding.
Choice B rationale
Suggesting that the partner take the client with them when going out may not be practical, especially considering the advanced stage of Alzheimer's disease. This response can show a lack of understanding of the challenges faced by caregivers of individuals with severe cognitive impairment.
Choice C rationale
Asking the partner to share more about their expectations opens a dialogue and shows empathy. It allows the nurse to understand the partner’s feelings and needs better, providing an opportunity for supportive and individualized advice.
Choice D rationale
While expressing understanding and sharing a personal experience might build rapport, it can shift the focus away from the partner's feelings and needs. The nurse should remain client-centered, providing support specific to the partner's situation rather than comparing it to their own.
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