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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Suggest the client exercise before going to bed: While exercise is beneficial for depression, vigorous activity before bedtime can interfere with sleep. It is generally better to recommend exercise earlier in the day to promote better rest and regulate mood.

B. Offer the client low-protein snacks throughout the day: Clients with major depressive disorder may experience changes in appetite, but offering low-protein snacks is not a specific therapeutic intervention. Balanced meals and snacks are more appropriate to support overall nutrition.

C. Encourage the client to use positive self-talk: Positive self-talk can help challenge and change negative thought patterns that are common in major depressive disorder. Encouraging cognitive restructuring strategies like positive affirmations supports emotional healing and coping.

D. Recommend the client spend time alone in his room: Isolation can worsen depressive symptoms by increasing feelings of loneliness and hopelessness. Encouraging social interaction and structured activities is more helpful in managing depression.

A. Vitamin D, B. Ranitidine C. Naproxen D. Docusate sodium

Correct Answer is C

Explanation

A. Vitamin D: Vitamin D is a supplement used to support bone health and calcium regulation. It does not have a known adverse interaction with clopidogrel and does not increase the risk of bleeding when taken concurrently.

B. Ranitidine: Ranitidine is an H2 receptor antagonist used to reduce stomach acid. It has minimal interaction with clopidogrel and does not significantly impact bleeding risk, making it generally safe to use alongside antiplatelet therapy.

C. Naproxen: Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of gastrointestinal bleeding when used with clopidogrel, an antiplatelet agent. Combining these medications heightens the risk of serious bleeding complications and should be avoided without provider guidance.

D. Docusate sodium: Docusate sodium is a stool softener that facilitates easier bowel movements. It does not have a significant interaction with clopidogrel and does not affect bleeding risk, making it generally safe for clients requiring antiplatelet therapy.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Explanation

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