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. Open nearby doors and windows when the fire alarm sounds: Opening doors and windows during a fire can cause the fire to spread more rapidly by feeding it with additional oxygen. Doors should be closed to contain the fire and reduce the spread of smoke.

B. Attempt to extinguish the fire before evacuating clients: Client safety is the priority in a fire situation. Evacuation should occur first, and attempts to extinguish the fire should only be made if it is safe to do so without putting clients or staff at risk.

C. Have ambulatory clients walk independently to a safe location: Ambulatory clients should be instructed to evacuate independently if they can do so safely, freeing staff to assist clients who are immobile or require more help during the evacuation.

D. Aim the spray of the fire extinguisher at the top of the fire: The proper technique is to aim at the base of the fire, not the top, to effectively extinguish the flames by removing the fire's source of fuel.

A. Discontinue use of electronics 30 min before bedtime. B. Drink a cup of coffee 1 hr before bedtime. C. Consume a meal 1 hr before bedtime. D. Exercise 1 hr before bedtime.

Correct Answer is A

Explanation

A. Discontinue use of electronics 30 min before bedtime: The use of electronics before bedtime can disrupt the body's natural sleep cycle by suppressing melatonin production. Stopping electronic use at least 30 minutes before bed promotes relaxation and better sleep quality.

B. Drink a cup of coffee 1 hr before bedtime: Caffeine is a stimulant that can interfere with falling asleep and maintaining deep sleep. Consuming coffee close to bedtime would likely worsen sleep disturbances rather than help.

C. Consume a meal 1 hr before bedtime: Eating a large meal close to bedtime can cause discomfort, indigestion, and difficulty falling asleep. Light snacks are acceptable, but heavy meals should be avoided before sleeping.

D. Exercise 1 hr before bedtime: Vigorous exercise shortly before bedtime can increase adrenaline and body temperature, making it harder to fall asleep. Exercise is better scheduled earlier in the day to support restful sleep.

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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?

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