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
Securing the catheter helps prevent it from moving, which reduces the risk of urethral trauma and infection. Proper fixation is essential for patient safety and comfort.
Choice B rationale
Urine should not be obtained from the drainage bag for specimen collection as it may be contaminated. Fresh urine samples directly from the catheter port are more accurate.
Choice C rationale
Catheter bags should be changed based on clinical need, which can be more frequent than every 3 days. This ensures hygiene and reduces infection risks.
Choice D rationale
The drainage bag should be kept below the bladder level to prevent backflow of urine, which can lead to infection.
Correct Answer is D
Explanation
Choice A rationale
Verbal consent alone is not sufficient for invasive procedures like urinary catheter insertion. Documented consent is necessary to ensure legal and ethical compliance.
Choice B rationale
Having another nurse co-sign the consent does not verify the client's explicit agreement to the procedure. It is important that the client’s direct consent is documented.
Choice C rationale
Checking the medical record for a previous consent form may not reflect the client's current willingness. Consent should be obtained fresh to confirm current understanding and agreement.
Choice D rationale
Witnessing the client's signature on a consent form ensures that the client has been informed and agrees to the procedure, fulfilling both legal and ethical requirements.
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