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 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.
Correct Answer is A
Explanation
A) Correct - Keeping the car seat rear-facing is recommended until your baby reaches the age of 2 or the weight and height limits specified by the car seat manufacturer. This is to provide maximum protection to the baby's developing head and neck.
B) Incorrect- Placing the shoulder harness at the level of the baby's shoulders is important, but the rear-facing position is a higher priority.
C) Incorrect- The retainer clip should be positioned at the level of the baby's armpits to ensure proper placement of the harness straps.
D) Incorrect- The angle of recline is important to prevent the baby's head from flopping forward, but the rear-facing position itself is more crucial.
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.