Question

yoa li has received morphine for pain, diazepam for anxiety, and prochlorperazine for nausea during the postoperative period. which assessment finding(s) require(s) immediate intervention by the nurse? (select all that apply.) respirations 10 breaths per minute blood pressure 102/62 mmhg heart rate 55 beats per minute spo2 90% capillary refill 5 seconds urine output 270 ml/3 hours

Answer 1

The clinical findings of respirations 10 breaths per minute, SpO2 90%, and capillary refill 5 seconds in a postoperative patient who has received morphine, diazepam, and prochlorperazine require immediate intervention to address potential respiratory depression, hypoxemia, and poor perfusion.

Step-by-step explanation:

The assessment findings that require immediate intervention by the nurse for a postoperative patient who has received morphine for pain, diazepam for anxiety, and prochlorperazine for nausea are:

• Respirations 10 breaths per minute
• SPO2 90%
• Capillary refill 5 seconds

A respiration rate of 10 breaths per minute is concerning and suggests respiratory depression, which is a known side effect of opioids like morphine. A SpO2 (oxygen saturation) of 90% is below the normal range (95-100%) and may indicate hypoxemia. A capillary refill time of more than 2 seconds suggests poor perfusion and is also a serious concern. These findings indicate that the patient may require interventions such as supplemental oxygen or reversal of opioid effects with medications such as naloxone.