Level: Foundational
Difficulty: Easy
Subtopic: Medication administration rights
NCLEX: A 55-year-old client in postanesthesia care is being evaluated for scheduled medications. Assessment data include…
Pharmacology Pharmacological and Parenteral Therapies
Case Study
A 55-year-old client in postanesthesia care is being evaluated for scheduled medications. Assessment data include the client has respiratory rate 10/min and is difficult to arouse after opioid administration. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that has respiratory rate 10/min and is difficult to arouse after opioid administration.
D. Routine data unchanged from the prior assessment.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that has respiratory rate 10/min and is difficult to arouse after opioid administration.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. The new finding that has respiratory rate 10/min and is difficult to arouse after opioid administration.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.