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
Reviewing the client's photograph in the medical record is an effective method to ensure accurate identification. This practice aligns with patient safety protocols and minimizes the risk of medication errors by confirming the patient's identity through a visual match with a documented image.
Choice B rationale
Requesting an assistive personnel to identify the client might be unreliable if the personnel is unfamiliar with the client or makes an error. This approach does not provide a secure verification method and could lead to mistakes.
Choice C rationale
Asking the client to state their room number is not reliable since a client with advanced dementia may not remember their room number accurately. This method does not ensure proper identification and can lead to errors.
Choice D rationale
Having the client state their phone number is inappropriate for clients with advanced dementia, who may struggle to recall such information. This method is not a secure or accurate way to verify identity.
Correct Answer is A
Explanation
Choice A rationale
Keeping elbows slightly bent when grasping the walker helps to maintain stability and control. This positioning reduces the strain on the arms and shoulders, providing a more comfortable and effective way to use the walker.
Choice B rationale
Sliding the walker and moving it about a foot in front can cause instability. Instead, lifting the walker and placing it step-by-step ensures better support and reduces the risk of falls.
Choice C rationale
Moving the walker and the stronger leg at the same time can lead to imbalance and falls. The correct method is to move the walker first, then step forward with the weaker leg, followed by the stronger leg.
Choice D rationale
Keeping the walker height adjusted so the user leans slightly forward is incorrect. The walker height should be at the level of the wrists when the arms are hanging down, allowing for a natural and upright posture.
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