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 C
Explanation
The Braden scale measures six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
“The higher the score, the higher the pressure injury risk”: This statement is incorrect.
The lower the score on the Braden scale, the higher the risk for pressure injury.
“Each element has a range from one to five points”: This statement is incorrect.
Each element has a range from one to four points, except for friction/shear which has a range from one to three points.
“The client’s age is part of the measurement”: This statement is incorrect. Age is not one of the elements measured by the Braden scale.
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.
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