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 ["0.5"]
Explanation
To administer the correct dose of lorazepam, which is 1 mg, when only 2 mg tablets are available, the nurse should administer half a tablet. This is because each tablet contains 2 mg of lorazepam, and the prescribed dose is 1 mg. Therefore, dividing the tablet into two equal parts will provide the necessary 1 mg dose. The answer, rounded to the nearest tenth as per the instruction, is 0.5.
Correct Answer is C
Explanation
A. A client with a leg ulcer may have limited mobility but not necessarily the highest fall risk.
B. An adolescent using crutches is at some risk but typically has better balance and coordination than older adults.
C. An older adult who is confused and has urinary frequency is at the highest risk for falls due to impaired cognitive function and frequent need to get up to use the bathroom, which increases the likelihood of falls.
D. A postoperative client with assistance is less likely to fall compared to an unassisted confused older adult.
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