A child diagnosed with strep throat 3 days ago enters the clinic crying hysterically. The parent tells the practical nurse (PN) that the child screams in pain even with a light touch. The child is short of breath and anxious. Which manifestations warrant immediate intervention by the
PN?
Slightly raised rash with ragged edges.
Red, hot, and swollen joints.
Heart rate 110 beats/minute.
Pulse oximetry of 88% O2 saturation.
Correct Answer : B,D
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Determining the means of evacuation requires understanding the facility's evacuation protocols, coordinating with authorities, and ensuring the safety of residents, which typically falls under the responsibility of the nursing staff, including the practical nurse (PN).
B. Closing fire doors and residents' room doors can be part of fire safety protocols and may involve the immediate safety response handled by both nursing staff and facility personnel.
C. Assisting wandering residents and offering comfort and reassurance to distraught residents can be tasks shared among nursing and support staff to ensure resident safety and well-being during an emergency situation.
Correct Answer is B
Explanation
A. Sodium level of 130 mEq/L is slightly below the lower limit of the reference range but might not have as immediate an impact on safety as a critically low hemoglobin level.
B. Hemoglobin of 8.9 grams/dL is significantly below the normal range and indicates a substantial drop in red blood cells, which can lead to impaired oxygen transport and potentially severe postoperative complications like inadequate tissue perfusion and oxygenation.
C. Potassium level of 3.4 mEq/L is slightly below the lower limit of the reference range but might not pose an immediate threat compared to a critically low hemoglobin level.
D. Blood urea nitrogen (BUN) of 20 mg/dL is at the upper limit of the reference range but might not have an immediate implication for client safety compared to a critically low hemoglobin level.
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