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 A
Explanation
A. This statement indicates a need for further teaching as a high fiber diet is not directly related to reducing the risk of skin cancer.
B. Avoiding tanning booths is appropriate advice for preventing skin cancer due to the high exposure to UV radiation.
C. Using sunscreen on cloudy days is good advice as UV rays can penetrate through clouds and still cause skin damage.
D. Regularly checking the skin for changes is important for early detection of skin cancer and is appropriate advice.
Correct Answer is D
Explanation
A. This statement is incorrect as it describes a condition related to diabetes insipidus, not diabetes mellitus.
B. This statement describes the autoimmune process in Type 1 diabetes, not Type 2 diabetes.
C. This statement is inaccurate for Type 2 diabetes; it is more related to acute pancreatitis or Type 1 diabetes.
D. Type 2 diabetes mellitus is characterized by insulin resistance and decreased insulin secretion by the pancreas.
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