A nurse is caring for a client.
Exhibits
Select the 4 findings that require immediate follow-up.

Temperature

Breath sounds

Blood pressure

Heart rate

Swollen tongue

Urticaria

Answer and Explanation

Correct Answer : B,C,D,E

A.   The presence of wheezing indicates potential airway compromise, which is a significant concern in the context of an allergic reaction. Wheezing suggests bronchoconstriction and difficulty breathing, requiring immediate assessment and intervention to ensure adequate oxygenation.
B.   significant drop in blood pressure (hypotension) is a red flag for anaphylaxis, a severe and potentially life-threatening allergic reaction. Hypotension can lead to inadequate tissue perfusion and organ dysfunction, requiring immediate intervention with fluids and medications to stabilize blood pressure.
C.   rapid heart rate (tachycardia) can be a sign of an allergic reaction, particularly if accompanied by other symptoms such as hypotension or respiratory distress. Tachycardia may indicate the body's response to hypotension or increased sympathetic activity, and it warrants immediate follow-up to assess for shock or other complications.
D.   Swelling of the tongue (angioedema) can compromise the airway and lead to respiratory distress or obstruction. It is a concerning sign that requires immediate intervention to ensure the client's airway remains patent and adequate ventilation is maintained.
E.   A While an elevated temperature can indicate an inflammatory response, it is not typically the most concerning finding in an allergic reaction. In this case, the temperature elevation is mild and may be secondary to the allergic reaction, but it is not a critical priority for immediate follow-up compared to other findings.
F .Urticaria (hives) is a common manifestation of an allergic reaction and can be uncomfortable for the client. While it is important to address, it is typically not as immediately life-threatening as other symptoms such as wheezing or angioedema.

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Correct Answer is D

Explanation

D. This statement shows a good understanding of measures to reduce the adverse effects of immobility. Regularly performing ankle and knee exercises helps promote circulation, prevent muscle atrophy, and reduce the risk of DVT and joint stiffness. Hourly exercises are an excellent practice to mitigate the negative effects of immobility.
A. This statement indicates a misunderstanding. Holding the breath while changing positions can lead to a Valsalva maneuver, which can cause a sudden drop in blood pressure and increase the risk of dizziness or fainting, especially in immobile clients. Instead, clients should be encouraged to breathe normally and rise slowly to avoid orthostatic hypotension.
B. This frequency of position changes is inadequate for preventing pressure ulcers. It is generally recommended to change positions at least every 2 hours to prevent pressure on any one area of the body for too long. Therefore, this statement indicates a partial understanding but needs adjustment to more frequent position changes.
C. Antiembolic stockings (TED hose) are designed to promote venous return and reduce the risk of DVT. They are typically worn continuously, except during hygiene routines or as directed by a healthcare

provider. Removing them while in bed could increase the risk of thrombus formation. This statement indicates a misunderstanding of their purpose and usage.

A. Loosen the client's clothing. B. Turn the client onto their side. C. Move items in the room away from the client D. Help the client lie on the floor.

Correct Answer is D

Explanation

A. Loosening the client's clothing is important to ensure adequate ventilation and prevent restriction during the seizure. However, it is not the first priority compared to ensuring safety and positioning the client to prevent aspiration.
B. Turning the client onto their side helps prevent aspiration of saliva or vomit and maintains a clear airway during the seizure. This position allows any fluids to drain out of the mouth and reduces the risk of airway obstruction.

C.Moving items in the room away may promote safety but does not addresss the client's issue directly as an emergency.
D. Lowering client on the fall is the first action to take followed by clearing the environment for safety.

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A nurse is caring for a client. Exhibits Select the 4 findings that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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A nurse is caring for a client.
Exhibits
Select the 4 findings that require immediate follow-up.