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 C
Explanation
“I should limit the time that I spend sitting in a chair.” This is important because sitting for long periods of time can increase the risk of thrombus formation.
Choice A is wrong because crossing the legs while sitting can impede blood flow and increase the risk of thrombus formation.
Choice B is wrong because leg exercises should be performed more frequently than once every 4 hours while awake.
Choice D is wrong because massaging the legs when they hurt can dislodge a thrombus and cause it to travel to other parts of the body.
Correct Answer is B
Explanation
A client with MRSA infection should be placed in a private room to prevent the spread of infection.
Choice A is wrong because an N95 respirator mask is not necessary when caring for a client with an MRSA infection.
Choice C is wrong because the proper sequence for removing personal protective equipment is to remove gloves first, then the gown.
Choice D is wrong because visitors do not need to wear a mask when they are within 3 feet of the client with an MRSA infection.
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