A nurse is caring for a client.
Vital Signs
0800:
- Temperature 37.6° C (99.7° F)
- Blood pressure 108/56 mm Hg
- Heart rate 66/min
- Respiratory rate 18/min
- Pulse oximetry 97% on room air
0830:
- Temperature 37.5° C (99.5° F)
- Blood pressure 88/56 mm Hg
- Heart rate 104/min
- Respiratory rate 24/min
- Pulse oximetry 93% on room air
Select the 4 findings that require immediate follow-up.
Temperature
Blood pressure
Respiratory rate
Pulse oximetry.
Heart rate.
Level of consciousness
Skin color and temperature
Correct Answer : B,C,D,E
The blood pressure has dropped significantly from 108/56 mm Hg to 88/56 mm Hg.
The pulse oximetry has decreased from 97% to 93%, indicating a decrease in oxygen saturation.
The heart rate has increased from 66/min to 104/min.
The level of consciousness is always an important factor to monitor in a patient.
A. Temperature: The temperature has only changed slightly and is within the normal range.
C. Respiratory rate: The respiratory rate has increased but is still within normal range.
G. Skin color and temperature: This information is not provided in the exhibit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A nurse can delegate the task of performing a simple dressing change to an assistive personnel.
Delegation is an essential nursing skill that allows a qualified healthcare worker, like an RN, to transfer routine and low-risk duties to nursing assistive personnel.
This frees up the RN’s time to address more pressing matters, including critical patients and tasks.
Choice A is wrong because changing IV tubing is not a task that can be delegated to assistive personnel.
Choice C is wrong because inserting an NG tube is not a task that can be delegated to assistive personnel.
Choice D is wrong because evaluating the healing of an incision is not a task that can be delegated to assistive personnel.
These tasks require the expertise and training of a licensed nurse.
Correct Answer is C
Explanation
“This test will provide information about the function of your liver.” An alanine aminotransferase (ALT) test measures the level of ALT in the blood, which is an enzyme found primarily in the liver.
Elevated levels of ALT can indicate liver damage or disease.
Choice A, “This test will indicate if you are at risk for developing blood clots,” is not correct as an ALT test does not provide information about blood clot risk.
Choice B, “This test will determine if your heart is performing properly,” is not correct as an ALT test does not provide information about heart function.
Choice D, “This test is used to check how your kidneys are working,” is not correct as an ALT test does not provide information about kidney function.
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