A nurse is collecting data from a client who is 12 hr postoperative following intestinal surgery. Which of the following findings should the nurse report to the charge nurse prior to client ambulation?

Oxygen saturation 90%

Respiratory rate 20/min

Apical pulse rate 88/min

Oral temperature 37.6° C (99.7° F)

Answer and Explanation

The Correct Answer is A

An oxygen saturation level of 90% is below the normal range and indicates inadequate oxygenation. This finding could indicate respiratory compromise or impaired lung function, which may require further assessment and intervention before allowing the client to ambulate.

The respiratory rate of 20 breaths per minute, apical pulse rate of 88 beats per minute, and oral temperature of 37.6°C (99.7°F) are within the expected range and do not raise immediate concerns that require reporting to the charge nurse prior to ambulation.

However, the nurse should continue to monitor these vital signs during and after ambulation to ensure stability.

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Correct Answer is C

Explanation

c. New onset of hearing loss.

When collecting data from a client who is receiving gentamicin via IV infusion, the nurse should identify new onset of hearing loss as an adverse eﬀect of the treatment¹. Gentamicin can cause vestibulocochlear nerve damage, which can aﬀect hearing and balance¹.

Correct Answer is ["1.5"]

Explanation

To calculate the required mL of morphine solution needed to administer 30 mg of morphine orally (PO), you can use the following formula:

Volume (in mL) = Amount (in mg) / Concentration (in mg/mL)

In this case, the amount of morphine is 30 mg, and the concentration of the morphine solution is 20 mg/mL.

Volume (in mL) = 30 mg / 20 mg/mL

Volume (in mL) = 1.5 mL

Therefore, the nurse should administer 1.5 mL of the morphine solution to deliver 30 mg of morphine to the client orally.

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A nurse is collecting data from a client who is 12 hr postoperative following intestinal surgery. Which of the following findings should the nurse report to the charge nurse prior to client ambulation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse eﬀect of the treatment?

Correct Answer is C

Explanation

A nurse is preparing to administer morphine 30 mg PO to a client who reports pain. Available is morphine solution 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["1.5"]

Explanation

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