A nurse in a walk-in clinic is caring for a client.
Which of the following six findings should the nurse report to the provider? Select the 6 findings that require immediate follow-up.
1300:
- Temperature 39.1° C (102.4° F)
- Heart rate 115/min
- Respiratory rate 30/min
- Blood pressure 99/58 mm Hg
- Oxygen saturation 93% on room air
1330:
- Temperature 39.2° C (102.5° F)
- Heart rate 118/min
- Respiratory rate 28/min
- Blood pressure 91/52 mm Hg
- Oxygen saturation 95% on 2 L/min nasal cannula
- Heart rate
- Skin turgor
- Temperature
- Heart sounds
- Blood pressure
- COVID test results
- Orientation
- Lung sounds
Temperature 39.1° C (102.4° F)
Blood pressure
Skin turgor
Temperature 39.2° C (102.5° F)
COVID test results
The Correct Answer is ["A","D"]
Temperature 39.1° C (102.4° F), Temperature 39.2° C (102.5° F)
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Injecting air into the short-acting insulin vial is the first action to be taken. When mixing short-acting and intermediate-acting insulins in the same syringe, the first step is to inject air into the short-acting insulin (clear) vial. This helps equalize the pressure within the vial, making it easier to withdraw the correct dose of insulin
Choice B reason:
Drawing up the desired dose of intermediate-acting insulin into the same syringe is incorrect because it is the last step to be taken.
Choice C reason:
Drawing up the desired dose of short-acting insulin into the syringe is incorrect because it is the third step to be taken.
Choice D reason:
Inject air into the intermediate-acting insulin (cloudy) vial is incorrect because it is the second step to be taken
Correct Answer is B, C, E, D, A
Explanation
B. Provide adequate lighting to inspect the abdomen: Adequate lighting is important to ensure that the nurse can clearly see and assess the client's abdominal area. This step helps identify any visible abnormalities, such as skin changes, scars, masses, or distention.
C. Listen to the abdominal arteries using the bell of a stethoscope: Listening to the abdominal arteries helps the nurse assess blood flow and detect any abnormal vascular sounds, such as bruits or murmurs. This step provides information about vascular health and potential issues related to blood flow.
E. Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen: Palpating and locating the liver and spleen borders help assess the size and position of these organs. It can help identify hepatomegaly (enlarged liver) or splenomegaly (enlarged spleen), which could indicate various underlying conditions.
D. Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen: Palpating the abdomen for tenderness helps identify areas of discomfort or pain. It can provide information about potential inflammation, organ enlargement, or other sources of discomfort.
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