A nurse is assessing a client who reports acute pain at a level of 7 on a scale of 0 to 10. Which of the following findings should the nurse expect?

Hypertension

Bradycardia

Decreased respiratory rate

Hypoglycaemia

Answer and Explanation

The Correct Answer is A

Pain can cause an increase in sympathetic nervous system activity, leading to vasoconstriction and increased heart rate, which can result in hypertension. Pain may also increase the release of stress hormones, such as cortisol and epinephrine, which can further contribute to increased blood pressure.

Bradycardia (slow heart rate) decreased respiratory rate, and hypoglycemia are not typical findings associated with acute pain.

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Correct Answer is B

Explanation

The correct answer is b.

Choice A: SpO2 95%

The normal range for SpO2, or peripheral capillary oxygen saturation, is typically between 95% and 100%. While a SpO2 of 95% is within the normal range, it doesn't necessarily indicate an understanding of vital signs as it's on the lower end of the normal range.

Choice B: Right radial pulse regular 68/min

The normal resting heart rate for adults ranges from 60 to 100 beats per minute. Therefore, a right radial pulse of 68 beats per minute falls within the normal range and indicates an understanding of vital signs.

Choice C: Temp 36°C (96.8°F)

The normal body temperature for a healthy adult can range from 97.8°F (36.5°C) to 99.1°F (37.3°C). Therefore, a body temperature of 36°C (96.8°F) is slightly below the normal range.

Choice D: BP 148/72 mm Hg

The normal range for blood pressure in adults is between 90/60 mmHg and 120/80 mmHg. A blood pressure reading of 148/72 mm Hg is above the normal range for systolic pressure (the top number), indicating high blood pressure (hypertension).

A. Place the client in a room with negative pressure airﬂow. B. Clean hands with soap and water after caring for the client. C. Apply a mask on the client when they are outside their room. D. Wash hands for 10 seconds after caring for the client.

Correct Answer is B

Explanation

Clostridium difficile (C. difficile) is a highly contagious bacteria that can cause diarrhea and colitis 1. To prevent the spread of infection, it is important for the nurse to practice good hand hygiene by washing their hands with soap and water after caring for the client.

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A nurse is assessing a client who reports acute pain at a level of 7 on a scale of 0 to 10. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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