A nurse is assisting in the care of a newly admitted client.
Vital Signs Day 1
0800:
Temperature 37.2 °C (99 °F. Heart rate 90/min Respiratory rate 18/min
Blood pressure 126/78 mm Hg Oxygen saturation 96% on room air Day 2
0800:
Which of the following findings should the nurse report immediately to the provider?
Select all that apply.
Heart rate
Pain
Cold, clammy skin
Mental confusion
Respiratory status
Blood pressure Scrum amylase level
Urine output
Temperature
Sodium level
Correct Answer : C,D,E
A. Heart rate: the patient’s heart rate is within the normal range
B. Pain: Pain should be addressed promptly, but it may not require immediate provider notification depending on the severity and cause.
C. Cold, clammy skin: Cold and clammy skin can be indicative of poor perfusion or shock, which requires prompt evaluation and intervention.
D. Mental confusion: Mental confusion can indicate a change in neurological status or impaired oxygenation, and it requires immediate assessment to determine the underlying cause.
E. Respiratory status: Changes in respiratory status, such as increased respiratory rate, difficulty breathing, or decreased oxygen saturation, could signify respiratory distress and require urgent attention.
F. Blood pressure: Changes in blood pressure may need attention, but they might not be as urgent as other critical findings.
G. Urine output: Monitoring urine output is important, but it may not require immediate notification unless there is a significant decrease or other concerning trends.
H. Temperature: While monitoring temperature is important, a slight increase alone may not warrant immediate provider notification.
I. Sodium level: Changes in sodium levels should be assessed, but they may not necessitate immediate reporting unless they are critically abnormal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. The bedside table should be within easy reach of the bed to prevent the client from attempting to reach for items and potentially falling.
B. Correct. Moving the client's bed to the main floor of the house reduces the need for using stairs, which can be a fall risk for clients at risk for falls.
C. Incorrect. Keeping the lighting dim increases the risk of falls. Adequate lighting is important to prevent falls.
D. Incorrect. Area rugs on slick floor surfaces can be hazardous and increase the risk of falls.
They should be removed or secured properly.
Correct Answer is A
Explanation
A. Correct. A warming sensation or a feeling of warmth throughout the body is a common sensation experienced by patients during an intravenous pyelogram due to the contrast dye used.
B. Limiting fluid intake is not typically necessary after an intravenous pyelogram; in fact, increased fluid intake is often recommended to help flush the dye from the body.
C. A signed consent form is usually required for invasive procedures like an intravenous pyelogram.
D. Eating or drinking before the procedure might interfere with the test results, so it is generally not allowed.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.