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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

Answer and Explanation

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.

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Correct Answer is C

Explanation

After administering an injection, a nurse should discard the needle in a puncture-proof container.
This is a recommended practice to ensure the safety of injections and related practices.
Choice A is wrong because removing the needle from the syringe is not necessary.
Choice B is wrong because recapping the needle before disposal is not recommended as it increases the risk of needlestick injuries.
Choice D is wrong because placing the needle on the bedside table poses a risk of injury and infection.

A. Administer antibiotics and bronchodilators. B. Initiate airborne precautions and isolation. C. Start the client on cough suppressants and antihistamines. D. Obtain sputum culture and chest X-ray.

Correct Answer is D

Explanation

The first two actions the nurse should take are to obtain a sputum culture and a chest X-ray.
These tests can help diagnose the cause of the client’s symptoms and guide treatment.
Choice A is wrong because administering antibiotics and bronchodilators should only be done after a diagnosis has been made.
Choice B is wrong because airborne precautions and isolation may not be necessary depending on the cause of the client’s symptoms.
Choice C is wrong because cough suppressants and antihistamines may not be appropriate treatments depending on the cause of the client’s symptoms.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer an injection to a client. Which of the following actions should the nurse plan to take after administering the injection?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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