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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Weighing oneself once weekly may not be frequent enough to monitor changes related to heart failure or medication effects.
B. Taking hydrochlorothiazide in the evening is not usually a crucial safety consideration; it is typically taken in the morning due to its diuretic effects.
C. Leaving a light on in the bathroom at night can prevent falls, which are a significant concern in older adults with heart failure.
D. Taking a hot bath before bedtime might not be a safety consideration related to heart failure or medication use and could potentially cause issues with temperature regulation or dehydration.
Correct Answer is B
Explanation
A. Logrolling is used to turn clients with spinal injuries, not typically for general immobile clients, and performing it every 4 hours might not be necessary or appropriate.
B. Using trochanter rolls beside the client's legs helps maintain proper alignment and prevents external rotation, which can lead to hip joint complications.
C. Placing the client's arms at their side when turning might restrict movement and not aid in proper alignment or comfort.
D. Crossing the client's ankles when lying supine might cause pressure injuries or discomfort due to increased pressure on the ankles.
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