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. Maintaining a lean body mass can be beneficial but may not directly prevent osteoporosis.
B. Weight-bearing exercises, such as walking, are known to help maintain bone density and prevent osteoporosis.
C. While vitamin B12 is essential for health, it's not specifically linked to osteoporosis prevention.
D. Water aerobics are good for overall fitness but might not have the same impact on bone health as weight-bearing exercises.

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

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 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 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 caring for a client who is postoperative and is on bed rest. Which of the following actions should the nurse take to decrease the client's risk of developing a pressure injury?

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 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 planning to change a client's tracheostomy ties. Which of the following actions should the nurse take?

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 is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)