The nurse is caring for a postpartum client who is receiving pain medication through an epidural catheter. Which assessment finding should the nurse report immediately to the physician?

Blood pressure: 120/80.

Pain rating of 4 on a scale of 1 to 10.

Pulse rate: 80.

Respiratory rate: 8.

Answer and Explanation

The Correct Answer is D

The nurse should immediately report a respiratory rate of 8 to the physician. A normal respiratory rate for an adult is between 12 and 20 breaths per minute. A respiratory rate of 8 is considered abnormally low and can indicate respiratory depression, which can be a side eﬀect of pain medication delivered through an epidural catheter. It is important for the nurse to report this finding immediately so that appropriate interventions can be taken to ensure the safety of the client.

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Correct Answer is B

Explanation

An appropriate outcome statement for a client with a discharge goal of improved mobility should be specific, measurable, achievable, relevant, and time-bound. In this case, the outcome statement "Client will ambulate without a walker by 6 weeks" meets these criteria. It specifies the desired outcome (ambulating without a walker), provides a measurable goal (6 weeks), is achievable and relevant to the client's goal of improved mobility, and includes a time frame for achieving the goal. The other statements are not specific or measurable enough to be considered appropriate outcome statements.

A. Questioning a medication order that does not appear to meet the client's needs for pain management. B. Practicing nursing in a culturally competent fashion. C. Exhibiting a willingness to try alternate methods of addressing a client's care needs. D. Waiting for the medical team to determine the focus of the client's supportive care. E. Listening with empathy to a client who has recently been diagnosed.

Correct Answer is ["A","C","E"]

Explanation

The manager observed the nurse performing actions that demonstrate critical thinking, including questioning a medication order that does not appear to meet the client's needs for pain management, exhibiting a willingness to try alternate methods of addressing a client's care needs, and listening to empathy to a client who has recently been diagnosed. These actions show that the nurse is able to think critically and make informed decisions based on the needs of the client.

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The nurse is caring for a postpartum client who is receiving pain medication through an epidural catheter. Which assessment finding should the nurse report immediately to the physician?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A discharge goal for a client is to have improved mobility. Which outcome statement did the nurse write appropriately?

Correct Answer is B

Explanation

The nurse manager has determined that a new staﬀ nurse is demonstrating characteristics of a critical thinker. Which of the following did the manager observe the nurse perform? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

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