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:
Evaluating the healing of an incision is not necessary because it involves clinical judgment and assessment skills, which are generally beyond the scope of practice for assistive personnel.
Choice B reason:
Changing IV tubing is a task that can often be safely delegated to an assistive personnel (AP) who has been trained and deemed competent to perform this task. It is within the AP's scope of practice and doesn't require clinical judgment or assessment.
Choice C reason:
Performing a simple dressing change involves direct contact with a wound and requires knowledge of aseptic technique and wound care principles. This task is typically performed by licensed nursing personnel.
Choice D reason:
Inserting an NG tube is a complex procedure that requires specialized training and skill. It should be performed by a licensed nurse or another healthcare professional with the appropriate training and competence.
Correct Answer is A
Explanation
Choice A reason:
False imprisonment is the correct answer because it occurs when a person intentionally restricts the freedom of movement of another person without proper consent or legal justification. In this scenario, the AP is threatening to place the client in restraints against their will if they do not comply with bed rest. This action is a violation of the client's rights and constitutes false imprisonment.
Choice B reason:
Defamation of character is incorrect: Defamation involves making false statements about someone that harm their reputation. It doesn't apply to this scenario.
Choice C reason:
Battery is incorrect: Battery involves intentional harmful or offensive physical contact with another person without their consent. There is no indication of physical contact in this situation.
Choice D reason:
Assault is incorrect. Assault refers to the intentional threat or act that causes fear of imminent harmful or offensive contact. While there is a threat implied in this scenario, the threat is of false imprisonment rather than physical harm, making false imprisonment a more accurate description of the tort.
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