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 B,A,C,D,E
Explanation
Choice A rationale
Unlocking and removing the inner cannula is the first step. It allows access to the inner cannula for cleaning and ensures that the tracheostomy tube remains patent.
Choice B rationale
Pouring 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin provides the necessary solution for cleansing the inner cannula and stoma site, helping to maintain sterility and prevent infection.
Choice C rationale
Scrubbing the inside and outside of the inner cannula with a small brush ensures that any mucus or debris is removed, reducing the risk of infection and maintaining clear airways.
Choice D rationale
Wiping the inside of the inner cannula with a folded pipe cleaner helps to remove any remaining debris or solution, ensuring that the inner cannula is thoroughly cleaned.
Choice E rationale
Cleansing the stoma site with 0.9% sodium chloride solution helps to remove any mucus or debris from the site, maintaining hygiene and reducing the risk of infection.
Correct Answer is C
Explanation
Choice A rationale
Injecting air into the ampule prior to drawing the medication into a syringe is incorrect because ampules are sealed glass containers, and injecting air could cause the liquid to spill out due to pressure changes.
Choice B rationale
Adding 0.5 mL of diluent to the medication is not appropriate for most medications in ampules unless specifically instructed by the medication guidelines. Ampules typically contain ready-to-use medication.
Choice C rationale
Using a filter needle to aspirate the medication is the correct action. A filter needle is used to prevent any glass particles from being drawn into the syringe, ensuring the medication is safe for administration.
Choice D rationale
Cleansing the tip of the ampule with an alcohol swab after opening is unnecessary because the ampule's contents are sterile and the risk of contamination is minimized if the ampule is handled correctly.
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