Try Naxlex NCLEX-RN (Free-Trial)

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.

A.

Heart rate

B.

Blood pressure

C.

Temperature

D.

Urticaria

E.

Swollen tongue

F.

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.
 


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is A

Explanation

A. Metabolic syndrome is a cluster of conditions that include high blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels, all of which increase the risk of cardiovascular disease.
B. Participation in competitive sports might enhance cardiovascular fitness and decrease the risk of cardiovascular diseases.
C. While alcohol use disorder can have health implications, it's not a direct risk factor for cardiovascular disease.
D. Hypotension (low blood pressure) is generally not considered a significant risk factor for cardiovascular disease, unlike hypertension (high blood pressure).

Correct Answer is A

Explanation

A. Anaphylactic reactions can cause a sudden and severe drop in blood pressure, which is a potentially life-threatening symptom. It's a hallmark sign of anaphylaxis.
B. A feeling of swelling in the feet might indicate a localized reaction but is less specific to anaphylaxis.
C. Pain at the injection site might occur due to local irritation but isn't typically a primary sign of an anaphylactic reaction.
D. A sudden decrease in heart rate is not a typical sign of an anaphylactic reaction.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register