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 A
Explanation
To calculate the dose of gentamicin to administer to a client who weighs 220 Ib, first convert the client’s weight from pounds to kilograms.
220 Ib is equivalent to 100 kg (220 Ib /.2 Ib/kg = 100 kg).
Then, multiply the client’s weight in kilograms by the dose of gentamicin per kilogram: 100 kg * 2 mg/kg = 200 mg.
Therefore, the nurse should administer 200 mg of gentamicin.
Choice B is wrong because 180 mg is not the correct dose.
Choice C is wrong because 400 mg is not the correct dose.
Choice D is wrong because 440 mg is not the correct dose.
Correct Answer is A
Explanation
Before administering medications via an NG tube, a nurse should dilute each crushed medication with sterile water.
Choice B is wrong because medications should not be combined with the formula in the feeding bag.
Choice C is wrong because the NG tube should be flushed with at least 15 to 30 mL of water before and after drug delivery.
Choice D is wrong because each medication should be administered separately when it is being given at the same time.
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