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
The nurse should first auscultate the client’s bowel sounds.
This will provide important information about the client’s gastrointestinal function and can help determine the cause of the client’s symptoms.
Choice A is wrong because while offering pain medication may provide temporary relief, it does not address the underlying cause of the client’s symptoms.
Choice C is wrong because palpating the abdomen before auscultating bowel sounds can alter the bowel sounds and make it more difficult to accurately assess the client’s condition.
Choice D is wrong because administering an antiemetic may provide temporary relief from nausea and vomiting, but it does not address the underlying cause of the client’s symptoms.
Correct Answer is A
Explanation
This is because chest percussion uses clapping of the chest using a cupped hand to vibrate the airways of the lungs and move and break apart the mucus inside the lungs.
Covering the area of percussion with a towel can help to reduce discomfort during the procedure.
Choice B is wrong because postural drainage should not be scheduled after meals.
It is best to schedule postural drainage before meals or at least 1-2 hours after meals to prevent discomfort or vomiting.
Choice Cis wrong because, during vibration, the client should inhale deeply and exhale slowly.
Choice Dis wrong because percussion should not be performed over the lower back.
It should be performed over the chest and back, avoiding areas such as the spine and breastbone.
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