A nurse is collecting data from an adolescent who is postoperative following a cesarean birth and is receiving morphine for pain. Which of the following findings is the nurse's priority?
Urinary retention
Respiratory rate 11/min
BP 105/62 mm Hg
Blurred vision
The Correct Answer is B
A) Incorrect- Urinary retention can be a concern but is not as immediately life-threatening as respiratory depression.
B) Correct - A respiratory rate of 11/min is significantly lower than the normal range and indicates respiratory depression, which can be life-threatening. It requires immediate attention.
C) Incorrect- A blood pressure of 105/62 mm Hg is within a normal range for an adolescent and does not require immediate intervention.
D) Incorrect- Blurred vision might be a side effect of medications, but respiratory depression takes priority due to its potential to lead to serious complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect- A 20-gauge needle is too large and could cause unnecessary pain for the newborn.
B) Correct - Choosing a 3/8-inch needle is appropriate for administering vaccines to newborns. he hepatitis B vaccine is given intramuscularly in the anterolateral thigh of newborns. The needle size should be appropriate for the muscle mass and age of the infant. A 3/8-inch needle is recommended for newborns, while a 20-gauge needle is too large and may cause tissue damage.
C) Incorrect- Administering the vaccine into the dorsal gluteal muscle is not recommended because of the risk of injury to the sciatic nerve; the recommended site is the vastus lateralis muscle in the anterolateral thigh.
D) Incorrect- The hepatitis B vaccine is usually administered in a dose of 0.5 mL for newborns, but this is not the only action that the nurse should take.
Correct Answer is C
Explanation
A) Incorrect- The angle of insertion for the hepatitis B vaccine is typically 90 degrees.
B) Incorrect- Obtaining parental consent is important for any medical procedure involving a minor, but it is not specific to the administration of the hepatitis B vaccine.
C) Correct - The first dose of the hepatitis B vaccine is usually given within the first 24 hours after birth to newborns whose mothers are hepatitis B positive to prevent vertical transmission.
D) Incorrect- The hepatitis B vaccine is usually administered into the vastus lateralis muscle in the newborn's thigh, not the dorsal gluteal muscle.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.