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
When preparing medication from a vial for subcutaneous injection for a client, the nurse should hold the vial with the top facing upward while injecting air into the vial.
This is because injecting air into the vial equalizes the pressure inside and makes it easier to withdraw the medication 1.
Choice A is wrong because holding the syringe so that bubbles collect at the level of the plunger is not necessary when preparing medication from a vial.
Choice C is wrong because injecting air into the vial with the eye of the needle immersed in the fluid can contaminate the medication.
Choice D is wrong because holding the syringe at a 45° angle is not necessary when verifying dosage.
Correct Answer is B
Explanation
This is because during the alarm reaction stage of general adaptation syndrome, which is also known as the fight-or-flight response, the sympathetic nervous system is activated by the sudden release of hormones.
This hormone release causes physical symptoms such as dilated pupils.
Choice A is wrong because depression is not a manifestation that occurs during the alarm reaction stage of general adaptation syndrome.
Choice C is wrong because bradycardia, or a slow heart rate, is not a manifestation that occurs during the alarm reaction stage of general adaptation syndrome.
Instead, an increase in heart rate is a common physical sign during this stage.
Choice D is wrong because physical exhaustion is not a manifestation that occurs during the alarm reaction stage of general adaptation syndrome.
Physical exhaustion occurs during the final stage of general adaptation syndrome, which is known as the exhaustion stage.
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