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. Pediculicide lotions are used to treat lice, not ticks. They are not effective or appropriate for tick removal.
B. Twisting a tick during removal can cause the mouthparts to break off and remain embedded in the skin, increasing the risk of infection.
C. Grasping the tick as close to the skin as possible with fine-tipped tweezers allows for complete removal without squeezing the tick's body.
D. Using a hot ember or match tip can cause the tick to regurgitate into the skin, increasing the risk of disease transmission.
Correct Answer is A
Explanation
Rationale:
A. Negligence involves failing to provide care that a reasonably prudent nurse would provide, such as leaving a shift early without proper handoff or notification, which could compromise patient safety.
B. Battery involves unlawful touching of a patient without consent, which is not applicable in this situation.
C. Slander involves making false spoken statements that harm a person's reputation, which is not applicable in this situation.
D. Libel involves making false written statements that harm a person's reputation, which is not applicable in this situation.
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