36. A nurse is caring for a client.
Exhibits
Which of the following findings at 1015 requires further action?
(Select all that apply.)
Low back pain
Urine color
Blood pressure
Respiratory rate
Correct Answer : C,D
A. While low back pain can be concerning, it's not an immediate priority compared to the vital sign changes. However, the nurse should document the pain and ask about its characteristics.
B. Brown-colored urine can sometimes indicate dehydration or certain medical conditions, requiring follow-up.
C. A significant drop in blood pressure (74/50 mmHg) indicates hypotension and requires immediate attention.
D. An increase in respiratory rate (28 breaths/min) suggests the client may be experiencing respiratory distress and needs evaluation.
E. The client’s oxygen saturation is 95% on room air which is normal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Tremor is not a common adverse effect of atenolol.
B. Constipation is not typically associated with atenolol.
C. Bradycardia (slow heart rate) is a known adverse effect of atenolol, a beta-blocker that can decrease heart rate and blood pressure.
D. Cough is more commonly associated with ACE inhibitors, not beta-blockers like atenolol.
Correct Answer is B
Explanation
A. Methotrexate is not typically associated with insomnia, and the timing of administration should be according to the provider's instructions.
B. Drinking 2 to 3 L of water per day helps prevent kidney damage and reduces the risk of side effects such as methotrexate toxicity.
C. Fever is not a common expected side effect of methotrexate and should be reported to the provider.
D. Combining methotrexate with NSAIDs can increase the risk of toxicity; this should only be done under direct medical supervision.
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