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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","C","E"]

Explanation

A. At the end of the shift is incorrect. Medication verification is done before administration, not at the end of the shift.

B. When removing the medication from the medication drawer is correct. This is the first check to ensure the correct medication is selected.

C. Directly before administering the medication is correct. This is the final check to verify that the correct medication, dose, route, and time match the prescription before giving it to the client.

D. When reconciling counts of controlled substances is incorrect. While controlled substances require counting and verification, this is separate from the three medication checks performed during administration.

E. When preparing the medication dosage is correct. This is the second check, ensuring that the correct medication and dose are prepared accurately before administration.

A. Wear clean gloves while cleaning the inner cannula. B. Cut a 4 inch x 4 inch (10 cm x 10 cm) gauze pad to place under the flanges of the tracheostomy tube. C. Cleanse the skin around the stoma with full-strength hydrogen peroxide. D. Secure the tracheostomy in place with a collar that has hook-and-loop fasteners.

Correct Answer is D

Explanation

A. Sterile gloves, not clean gloves, should be worn when cleaning the inner cannula to reduce the risk of introducing infection into the tracheostomy site, which is a direct pathway to the airway.

B. Placing gauze pads under the flanges of the tracheostomy tube isn't a standard practice for tracheostomy care.
C. Cleansing the skin around the stoma with full-strength hydrogen peroxide can be too harsh and irritating to the skin.
D. Using a tracheostomy collar with hook-and-loop fasteners is a safe and effective way to secure the tracheostomy tube, ensuring it remains in place while minimizing the risk of skin breakdown and irritation. This method also allows for easier adjustment and replacement of the collar.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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.)

Correct Answer is ["B","C","E"]

Explanation

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?

Correct Answer is D

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.

A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

A nurse is teaching a client who has decreased mobility about passive range-of-motion exercises. Which of the following statements should the nurse make?

A nurse is collaborating with a risk management team about potential legal issues involving client care. The nurse should identify that which of the following situations is an example of negligence?

A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?

A nurse is assessing a client who received an IM antibiotic injection 15 min ago. Which of the following findings should the nurse identify as an indication of a possible anaphylactic reaction to the medication?

A nurse is preparing to provide postmortem care for a client. Which of the following actions should the nurse plan to take?

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