A nurse is assisting with the care of a client
Select the 3 findings that require immediate follow-up.
Breath sounds at 1600
Temperature
Urticaria
Blood pressure at 1630
Report of dysphagia
Correct Answer : C,D,E
A. Bilateral breath sounds clear and present throughout at 1600 are normal findings and do not require immediate follow-up.
B. The temperature at both 1600 (37.6°C) and 1630 (37.5°C) is slightly elevated but not critically high. It does not require immediate follow-up unless it worsens significantly or is accompanied by other concerning symptoms.
C. Urticaria (hives) over the chest and trunk, along with itching and difficulty swallowing (dysphagia), are signs of an allergic reaction, which requires immediate follow-up and assessment.
D. The blood pressure decreased to 78/52 mm Hg at 1630 from 110/58 mm Hg at 1600. This significant drop indicates hypotension and requires immediate follow-up.
E. Difficulty swallowing (dysphagia) reported by the client suggests a potential airway compromise and requires immediate follow-up to assess the severity and intervene accordingly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. To achieve the prescribed dose of 75 mg and since Lopressor is available in 50 mg tablets, the nurse should administer 1 tablet (50 mg) plus another half tablet to make up the remaining 25 mg, totaling 1.5 tablets.
B. To achieve the prescribed dose of 75 mg and since Lopressor is available in 50 mg tablets, the nurse should administer 1 tablet (50 mg) plus another half tablet to make up the remaining 25 mg, totaling 1.5 tablets.
C. To achieve the prescribed dose of 75 mg and since Lopressor is available in 50 mg tablets, the nurse should administer 1 tablet (50 mg) plus another half tablet to make up the remaining 25 mg, totaling 1.5 tablets.
D. To achieve the prescribed dose of 75 mg and since Lopressor is available in 50 mg tablets, the nurse should administer 1 tablet (50 mg) plus another half tablet to make up the remaining 25 mg, totaling 1.5 tablets.
Correct Answer is B
Explanation
A. Turning on the television can be distracting and hinder the client's ability to focus on the educational session.
B. Providing educational material at a 6th grade reading level ensures the information is accessible and understandable, enhancing the client's comprehension and adherence to the medication regimen.
C. Using technical language can confuse the client and make it difficult to understand important information about the medication.
D. Beginning with the least important information can cause the client to miss crucial details, so it is best to start with the most important points.
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.