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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Free Nursing Study Resources

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

Explanation

A. Assessing skin temperature and color is crucial to ensure circulation and skin integrity before applying restraints.
B. Attaching restraints to the bed rail isn't considered best practice, as it can lead to entrapment and injury.
C. Ensuring the client's bed is in the lowest position is essential to prevent falls and reduce the risk of injury if the client attempts to leave the bed.
D. Padding bony prominences helps prevent skin breakdown and discomfort.
E. Securing restraints to allow two fingers and not three,to slide under them ensures proper fit and prevents excessive tightness that could impair circulation.

A. A nurse begins a blood transfusion without obtaining consent from a client. B. An assistive personnel prevents a client from leaving the facility. C. A nurse administers a medication without first identifying the client. D. An assistive personnel discusses client care in the facility cafeteria with visitors present.

Correct Answer is C

Explanation

A. Starting a blood transfusion without obtaining consent is a violation but may fall more under the category of battery than negligence.
B. Preventing a client from leaving the facility might relate more to issues of false imprisonment or breach of autonomy rather than negligence.
C. Administering medication without properly identifying the client can be considered negligence as it breaches the standard duty of care.
D. Discussing client care in a public area with visitors present might breach confidentiality but might not be categorized as negligence unless sensitive or protected information was disclosed.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a prescription for extremity restraints to both wrists. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

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

Explanation

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?

Correct Answer is C

Explanation

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 reposition a client who has a lower back injury. Which of the following actions should the nurse take?

A nurse is preparing to teach a female client about osteoporosis prevention. Which of the following recommendations should the nurse make for this client?

A newly licensed nurse has forgotten their password and asks another nurse to access the computer system for them so they can document care before transferring the client to another unit. Which of the following responses should the nurse make?

A nurse manager overhears a nurse telling a client, "I will administer your medication by injection if you don't swallow your pills." The nurse manager should identify that the nurse is committing which of the following torts?

A nurse is collecting a blood pressure (BP) reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mm Hg. Which of the following actions should the nurse take?

A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, "I want to die now that my partner is gone." Which of the following responses should the nurse make?

A nurse is caring for a client who has left lower-lobe atelectasis. In which of the following positions should the nurse place the client for postural drainage?