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 ["7"]
Explanation
Step 1: mg/kg/day × 35 kg = 2800 mg/day
Step 2: 0 mg/day ÷ 4 doses/day = 700 mg/dose.
Step 3: mg ÷ (1 g/10 mL) = 700 mg ÷ (1000 mg/10 mL)
Step 4: mg ÷ 100 mg/mL = 7 mL.
The nurse should administer 7 mL per dose.
Correct Answer is B
Explanation
Choice A rationale
Administering vaginal cream is a medication administration task requiring knowledge and skills within the licensed nurse's scope of practice. Assistive personnel (AP) are not authorized to perform this procedure due to the potential for complications and the need for clinical judgment.
Choice B rationale
Providing postmortem care is a task that AP can perform as it involves basic care activities, such as bathing and positioning, which do not require specialized nursing skills. This allows the nurse to focus on more complex patient needs.
Choice C rationale
Suctioning a tracheostomy is a procedure that requires clinical assessment and intervention skills. Due to the potential for complications, it is within the licensed nurse's scope of practice, not the AP's.
Choice D rationale
Changing a peripheral IV dressing involves assessment skills and requires sterile technique to prevent infection. This task is beyond the scope of practice for AP and should be performed by a licensed nurse.
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