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 B

Explanation

A. Turning the client onto their side helps prevent aspiration and ensures a clear airway but since the client is seated on a chair, they run the risk of getting a fall hence lying them down is the priority.
B. If a client has a seizure when seated, it is best to ensure their safety by lying them on the floor and moving any objects that can cuase injury.
C. Loosening clothing is important but not the priority over ensuring a clear airway.
D. Moving items away from the client is important to prevent injury, but ensuring airway safety comes first.

A. Mini Nutritional Assessment screening tool score B. History of hyperlipidemia C. History of malnutrition D. History of diabetes mellitus E. Cholesterol level F. Prealbumin level

Correct Answer is ["C","D","F"]

Explanation

A. Mini Nutritional Assessment screening tool score: While it indicates the risk of malnutrition, it's not directly linked to delayed wound healing.
B. History of hyperlipidemia: Hyperlipidemia itself doesn't directly affect wound healing.
C. History of malnutrition: Malnutrition significantly hampers the body's ability to heal wounds effectively.
D. History of diabetes mellitus: Diabetes can impair wound healing due to poor blood sugar control affecting the immune system and circulation.
E. Cholesterol level: Elevated cholesterol, while relevant to overall health, is not directly linked to delayed wound healing.
F. Prealbumin level: Prealbumin is a marker for nutritional status; lower levels indicate inadequate protein intake and can contribute to delayed wound healing.

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Naxlex Comprehensive Predictor Exams

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 B

Explanation

A nurse is caring for a client who is scheduled for surgery. Exhibits The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply.

Correct Answer is ["C","D","F"]

Explanation

A nurse is preparing to administer medications to a client. At which of the following times should the nurse compare the medication administration record and the medication label? (Select all that apply.)

A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?

A nurse is preparing to perform an anthropometric assessment on a client. Which of the following client data should the nurse include?

A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?

A nurse is prioritizing care for a client. Which of the following procedures should the nurse perform first?

A nurse is caring for an adolescent client who has full-thickness burns on their leg. The client expresses concern about their future. Which of the following is a therapeutic response by the nurse?

A nurse is planning care for a client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to Include?

A nurse is caring for a client who is anxious about being admitted to a health care facility for the first time. Which of the following statements should the nurse make?