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 C
Explanation
A. To find the number of tablets to administer: 0.25 mg (prescribed dose) ÷ 0.125 mg/tablet (available dose) = 2 tablets.
B. To find the number of tablets to administer: 0.25 mg (prescribed dose) ÷ 0.125 mg/tablet (available dose) = 2 tablets.
C. To find the number of tablets to administer: 0.25 mg (prescribed dose) ÷ 0.125 mg/tablet (available dose) = 2 tablets.
D. To find the number of tablets to administer: 0.25 mg (prescribed dose) ÷ 0.125 mg/tablet (available dose) = 2 tablets.
Correct Answer is B
Explanation
A. Giving a report outside the client’s room might miss out on involving the patient in their care and ensuring privacy.
B. Bedside reporting allows for direct observation of the patient, involvement in care planning, and verification of information, which can improve safety and communication.
C. A conference area might be suitable but does not allow for the direct involvement of the patient and immediate clarification of concerns.
D. The nurse’s lounge is not an appropriate place for handoff reports as it can be noisy and lacks direct patient involvement.
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