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 overhead lights to a bright setting may not be appropriate as it can be discomforting for the family and doesn't align with providing respectful postmortem care.
B. Inviting the family to assist in washing the client's body can be a part of therapeutic postmortem care and can help the family members in their grieving process.
C. Removing dentures for the family to keep isn't typically part of postmortem care.
D. Leaving the client's eyes open until the family views the body may not be culturally appropriate and can be distressing for the family.

A. "You should discuss these feelings with your provider." B. "Have you thought about harming yourself?" C. "Why did you stop taking your medication?" D. "Tell me more about your partner."

Correct Answer is B

Explanation

A. Advising to discuss with the provider doesn't address the immediate concern of potential harm.
B. Asking about thoughts of self-harm assesses the client's immediate safety.
C. Inquiring about medication discontinuation is important but not as urgent as addressing suicidal ideation.
D. While understanding the relationship is important, it's not the priority when a client expresses suicidal thoughts.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

Explanation

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?

Correct Answer is B

Explanation

A nurse is planning care for a client who has acute pain as a result of a pressure injury to the sacrum. Which of the following nonpharmacological interventions should the nurse include in the plan?

A nurse is admitting a client who is at risk for falls to a medical-surgical unit. Which of the following actions should the nurse take?

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?

A nurse is preparing to administer packed RBCs to a client who has a low hemoglobin level. Which of the following actions should the nurse take prior to the start of the infusion?

A nurse in a provider's office is caring for a client. Exhibits The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for osteoporosis? (Select all that apply.)

A nurse is providing discharge teaching about safety considerations to an older adult client who lives at home. The client has heart failure and a new prescription for hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching?

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 obtaining a health history from a client. Which of the following factors places the client at risk for cardiovascular disease?