A nurse is caring for a client.

Vital Signs

0800:

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 Nurses' Notes

0800:

Antibiotic administered as prescribed.

Bilateral breath sounds clear and present throughout. 0830

Client reports itching over the chest area and has urticaria over chest and trunk.

Client states tongue feels swollen

Bilateral breath sounds with scattered wheezing upon auscultation, Select the 4 findings that require immediate follow-up.

Heart rate

Blood pressure

Temperature

Urticaria

Swollen tongue

Breath sounds

Answer and Explanation

Correct Answer : B,D,E,F

A.   While elevated (104/min), it's essential, but not as critical as other findings.
B.   The significant drop in blood pressure from 108/56 mm Hg to 88/56 mm Hg within 30 minutes is a cause for immediate concern.
C.   The slight increase in temperature (from 37.6°C to 37.5°C) is important but not the most pressing concern.
D.   Itching over the chest with urticaria (hives) suggests an allergic reaction, requiring urgent attention.
E.   Swelling of the tongue is a severe sign of an allergic reaction and requires immediate intervention.
F.   Clear and present breath sounds with scattered wheezing indicate potential airway compromise, requiring immediate follow-up.

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Correct Answer is A

Explanation

A. Aspiration risk due to frequent coughing while eating is the priority as it can lead to aspiration pneumonia.
B. Blood pressure elevation may need attention but is secondary to the immediate risk of aspiration.
C. Nutritional intake is important, but immediate safety concerns like the risk of aspiration take precedence.
D. Leaning to the left side while sitting might indicate a motor deficit but doesn't present an immediate risk compared to aspiration.

A. There is an area rug covering a tile floor. B. Grab bars are installed in the shower. C. Prescriptions are stored in a medication organizer. D. The hot water heater is set to 47°C (117°F).

Correct Answer is A

Explanation

Rationale for A: Area rugs pose a significant tripping hazard for older adults, especially for those with osteoporosis who are at an increased risk for fractures if they fall. The nurse should intervene by advising the client to remove the area rug to prevent falls.

Rationale for B: Grab bars installed in the shower are a safety feature that helps prevent falls, especially for clients with mobility issues. This is a positive finding and does not require intervention.

Rationale for C: Storing prescriptions in a medication organizer helps the client keep track of their medications and prevents confusion, especially in older adults. This is an effective way to manage medications and does not need intervention.

Rationale for D: The hot water heater set to 47°C (117°F) is within the safe range to prevent burns while still providing sufficient warmth for bathing. This does not pose a risk to the client, and no intervention is needed.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?

Correct Answer is A

Explanation

A home health nurse is assessing the home environment of an older adult client who has osteoporosis. For which of the following findings should the nurse intervene?

Correct Answer is A

Explanation

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