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 B

Explanation

B. Metabolic syndrome is a cluster of conditions that occur together, increasing the risk of heart disease, stroke, and type 2 diabetes. These conditions include high blood pressure, high blood sugar levels, excess body fat around the waist, and abnormal cholesterol or triglyceride levels.
A. Participation in competitive sports may promote cardiovascular health through physical activity, reducing the risk of cardiovascular disease in most cases.
C. Family history of alcohol use disorder is not a direct risk factor for cardiovascular disease. However, excessive alcohol consumption itself can contribute to cardiovascular problems.
D. Hypotension, or low blood pressure, is not typically considered a risk factor for cardiovascular disease. In fact, it may be associated with a reduced risk of certain cardiovascular conditions such as hypertension and coronary artery disease. However, severe hypotension may lead to inadequate blood flo to the heart and brain, potentially causing cardiovascular complications.

A. Administer metronidazole. B. Don protective eyewear before entering the room. C. Wear a mask when working within 3 feet of the client. D. Place the client in a negative airflow room.

Correct Answer is C

Explanation

C. Wearing a mask when working within close proximity to the client helps prevent the transmission of respiratory droplets containing the influenza virus. This is especially important when providing direct care to the client, such as during assessments or procedures.
A. Metronidazole is an antibiotic used to treat bacterial infections, not viral infections like influenza. Administering metronidazole would not prevent the spread of influenza.
B. Protective eyewear is typically used to prevent exposure to bloodborne pathogens or other bodily fluids that could splash into the eyes. In the case of influenza, the primary mode of transmission is through respiratory droplets, so protective eyewear is not necessary for preventing its spread.
D. Negative airflow rooms are typically used for clients with airborne infections, such as tuberculosis, where there is a risk of droplet nuclei remaining suspended in the air for prolonged periods. Influenza is primarily spread through respiratory droplets and does not require negative airflow isolation.

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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

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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