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 B
Explanation
Choice A reason:
Needing a new hearing aid every year is not accurate. Hearing aids are not typically replaced annually unless there is a specific issue or significant changes in hearing.
Choice B reason:
"I should gradually increase the time that I wear the hearing aid. “This statement indicates an understanding of the appropriate approach to adapting to a new hearing aid. Gradually increasing the time spent wearing the hearing aid allows the individual to acclimate to the new sounds and avoid overwhelming the auditory system. Starting with shorter periods of use and gradually extending the time can help improve comfort and effectiveness.
Choice C reason:
Leaving the battery in the hearing aid when not in use can lead to battery drain and potential damage. It's important to remove the battery when the hearing aid is not being used.
Choice D reason:
Turning the hearing aid up to the highest volume immediately after insertion is not appropriate. Starting at a lower volume and gradually adjusting as needed is a more appropriate approach to prevent discomfort or potential damage to the ears.
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
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