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 D

Explanation

A. Loosening the bed linensmay not have a significant effect on the client's pain level, and may increase the risk of infection or further injury to the pressure ulcer.
B. Massaging the sacrum in the context of a pressure injury might exacerbate the condition and isn't recommended.
C. Providing bright lights might not specifically address the acute pain from the pressure injury.
D. Music therapy is a nonpharmacological intervention that can help reduce pain perception, anxiety, and stress in clients who have acute pain. Music can also provide distraction, relaxation, and comfort to the client.

A. Adjust the oxygen flow rate as needed to ease breathing. B. Antibiotic therapy should be taken for 10 days. C. Store the oxygen cylinder wrench with the oxygen tank. D. Ensure the oxygen delivery system is at least 8 feet from any heat source. E. Steroid medication should be taken in the morning. F. Antibiotic medication can be taken with or without food. G. The steroid dose will decrease each day.

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

Explanation

A. Adjusting the oxygen flow rate helps maintain adequate oxygen levels, especially during exertion or increased dyspnea.
B. The antibiotics were discontinued on Day 4, so the duration of antibiotic therapy is not 10 days.
C. Storing the wrench with the oxygen tank ensures that it's readily available to adjust or replace the tank.
D. Placing the oxygen delivery system away from heat sources helps prevent potential fire hazards.
E. There is no specifications on the time to take steroid medications
F. The specific instructions for taking the antibiotics weren't provided in the scenario.
G. The scenario doesn't specify a decreasing dose regimen for the steroid medication.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

A nurse is caring for a client who has pneumonia Exhibits The nurse is providing discharge teaching for the client and their caregiver. Which of the following information should the nurse include? Select all that apply.

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

Explanation

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 performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect?

A nurse is caring for a client who is scheduled for a surgical procedure Exhibits Select the 4 findings that require immediate follow-up.

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 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.)

A nurse is conducting the Weber's test on a client. Which of the following is an appropriate action for the nurse to take?

A nurse is teaching a client who can only bear weight on one leg how to ambulate using crutches. Which of the following crutch gaits should the nurse plan to instruct the client to use?

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