A nurse is caring for a client.
Exhibit 1 Vital Signs 0800: Exhibit 2 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,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 D
Explanation
During the contemplation stage of health behavior change, the client is thinking about change and becoming motivated to get started.
The nurse should present information about the benefits of quitting smoking to help the client assess the benefits of change.
Choice A is not correct because developing a plan for the client to integrate the change into her lifestyle is more appropriate for the preparation stage.
Choice B is not correct because recommending small changes for the client to make to change her behavior over time is more appropriate for the action stage.
Choice C is not correct because assisting the client in setting goals to make the change is more appropriate for the preparation stage.
Correct Answer is A
Explanation
A nurse should apply a bath blanket between the client and a cooling blanket when caring for a client who has a high fever.
This can help regulate the temperature of the environment and make it more comfortable for the patient.
Choice B is wrong because placing ice packs on the client’s neck and behind the knees is not recommended as it can cause further problems.
Choice C is wrong because giving the client a sponge bath using an alcohol-water solution is not recommended.
Choice D is wrong because covering the client with heavy blankets after the shivering subsides is not recommended as it can increase body temperature.
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