A nurse is collecting data from a client who is receiving hydromorphone for pain management. For which of the following findings should the nurse notify the provider?
Oxygen saturation 95%
Respiratory rate 14/min
Urinary output 160 mL/8hr
Blood pressure 108/58 mm Hg
The Correct Answer is C
A. Oxygen saturation 95%: An oxygen saturation of 95% is within normal limits for most clients and does not indicate respiratory compromise. No immediate provider notification is necessary based solely on this oxygen saturation level during opioid therapy.
B. Respiratory rate 14/min: A respiratory rate of 14 breaths per minute is normal. Significant respiratory depression from opioids like hydromorphone would typically be indicated by a rate lower than 12 breaths per minute.
C. Urinary output 160 mL/8 hr: Urinary output should be at least 30 mL/hr. A total of 160 mL in 8 hours is significantly low, suggesting possible urinary retention or decreased renal perfusion, both of which can be side effects of opioid use and should be reported promptly.
D. Blood pressure 108/58 mm Hg: While this blood pressure is on the lower side, it is not critically low for many adults. Unless the client is symptomatic with dizziness or fainting, this blood pressure alone does not require immediate provider notification.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. "The client in room 204 received some pain medicine earlier today": This statement is vague and nonspecific, lacking essential information such as the type of pain medication, dose, timing, and client response. Change-of-shift reports require clear, detailed, and actionable information to ensure continuity of care.
B. "The client in room 205 has had several visitors today": Information about visitors is generally not relevant to clinical care unless it impacts the client's condition. Reporting should focus on clinical updates, treatments, medications, or changes in the client’s status that require attention from the incoming nurse.
C. "The client in room 204 has a new prescription for gentamicin": This statement provides important clinical information regarding a change in the medication regimen. It alerts the next nurse to monitor for potential side effects, such as nephrotoxicity or ototoxicity, associated with gentamicin use.
D. "The client in room 203 will undergo surgery at 0900 tomorrow": Communicating scheduled surgeries is critical for planning preoperative care, ensuring that preoperative checklists are completed, and managing fasting requirements. It allows the next shift to prepare the client properly and coordinate care.
E. "The client in room 205 is scheduled for a dressing change at 1800": Including scheduled treatments like dressing changes ensures that important interventions are completed on time. It also helps the incoming nurse prioritize tasks and manage the shift effectively to meet the client’s care needs.
Correct Answer is C
Explanation
A. A client who is displaying aggression: Using a gait belt on an aggressive client is unsafe because sudden movements or resistance could lead to injury for both the client and the caregiver. Aggressive behavior requires de-escalation strategies before considering physical assistance or mobility interventions like a gait belt.
B. A client who has had chest trauma: Gait belts should be avoided in clients with chest trauma because the pressure applied around the torso can exacerbate injuries such as rib fractures, pulmonary contusions, or other thoracic complications, posing significant health risks during mobilization.
C. A client who has limited arm strength: A gait belt is appropriate for clients with limited arm strength because it provides secure support around the waist without requiring the client to rely heavily on their upper limbs. It allows for safer ambulation and transfer by offering the caregiver a firm point of control.
D. A client who has a thoracic incision: Applying a gait belt over or near a thoracic incision can interfere with wound healing, cause pain, and increase the risk of wound dehiscence. Alternative methods for assisting mobility should be used for clients with fresh surgical sites in the thoracic region.
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