A preschool-age client is hospitalized following surgery for a ruptured appendix. During assessment of the child, the nurse notes that the child is sleeping
Vital signs are as follows: temperature 97.8 degrees F axillary, pulse 90, respirations 12, and blood pressure 100/60. Which conclusion by the nurse is appropriate based on the assessment findings?
1. The client is comfortable and the pain is controlled.
2. The client is in shock secondary to blood loss during surgery.
3. The client is experiencing respiratory depression secondary to opioid administration for postoperative pain.
4. The client is sleeping to avoid pain associated with surgery.
Correct Answer: 3
Rationale: Respiratory depression secondary to opioid use is most likely to occur when the child is sleeping. A respiratory rate of 12 is well below normal for a preschool-age client. The other vital signs are within normal limits for a sleeping preschool-age client.
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