A nurse is caring for a client.
Vital Signs.
1600: Nurses' Notes.
Temperature 37.6°C (99.7°F). Blood pressure 110/58 mm Hg. Heart rate 72/min.
Respiratory rate 18/min.
Pulse oximetry 98% on room air.
1630: Temperature 37.5°C (99.5°F). Blood pressure 78/52 mm Hg. Heart rate 112/min.
Respiratory rate 26/min.
Pulse oximetry 92% on room air.
1600: Antibiotic administered as prescribed.
Bilateral breath sounds clear and present throughout.
1630: Client reports itching on the chest and has urticaria over the chest and trunk.
Client states they are having difficulty swallowing and feel as if there is a lump in their throat.
Bilateral breath sounds with scattered wheezing heard throughout.
Vital Signs.
Nurses' Notes.
Medication Administration Record.
Cefaclor 500 mg PO q8h.
Select the 3 findings that require immediate follow-up.
Breath sounds at 1600.
Temperature.
Urticaria.
Blood pressure at 1630.
Report of dysphagia.
Correct Answer : C,D,E
The correct answer is to select the following three findings that require immediate follow-up: C. Urticaria, D. Blood pressure at 1630, and E. Report of dysphagia.
Choice A rationale:
“Breath sounds at 1600.” The breath sounds at 1600 were clear and present throughout, which is a normal finding and does not require immediate follow-up.
Choice B rationale:
“Temperature.” The temperature readings at both 1600 and 1630 are slightly elevated but not critically high. This does not require immediate follow-up compared to the other findings.
Choice C rationale:
“Urticaria.” The presence of urticaria (hives) indicates an allergic reaction, which can potentially escalate to a more severe reaction such as anaphylaxis. Immediate follow-up is necessary to prevent further complications.
Choice D rationale:
“Blood pressure at 1630.” The blood pressure at 1630 is significantly lower (78/52 mm Hg) compared to the earlier reading (110/58 mm Hg). This hypotension could indicate a serious reaction to the medication or another underlying issue that requires prompt attention.
Choice E rationale:
“Report of dysphagia.” The client’s report of difficulty swallowing and feeling a lump in their throat is concerning for a potential airway obstruction or severe allergic reaction, such as anaphylaxis. This symptom requires immediate follow-up to ensure the client’s airway remains open and to provide necessary interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
In the SOAP charting model, the subjective component is where the client's subjective information and feelings are documented. This includes the client's own reports of symptoms, sensations, and experiences. In this case, the client reporting chest pain after mowing the lawn this morning is a subjective statement made by the client. This information is valuable as it provides insight into the client's perception of their condition and helps healthcare providers understand their symptoms and experiences.
Choice B rationale:
The blood pressure reading (182/98 mm Hg) is an objective measurement, not a subjective statement from the client. Objective data includes measurable and observable information, like vital signs, lab results, and physical examination findings. This type of information is typically documented in the objective component of SOAP charting.
Choice C rationale:
The administration of nitroglycerin (0.3 mg SL) is also an objective action taken by the client, not a subjective statement. It falls under the plan section of the SOAP chart, where healthcare providers outline the actions or interventions taken.
Choice D rationale:
The description of the client's skin (pale and diaphoretic) is also objective data. It represents observable physical signs and is not part of the subjective component, which focuses on the client's own statements and feelings.
Correct Answer is C
Explanation
Choice A rationale:
The National Student Nurses Association is primarily focused on students and recent graduates. While it can be an excellent organization for student nurses, it may not provide opportunities for a nurse looking to become involved in nursing on a national level beyond their student years.
Choice B rationale:
The National Academy of Medicine is an organization that focuses on health policy and research. While it is a prestigious organization, it is not specifically a nursing organization, and its focus may not align with the goals of a nurse seeking to become more involved in nursing on a national level.
Choice C rationale:
The American Nurses Association (ANA) is a national organization specifically dedicated to advancing the nursing profession. It offers various opportunities for nurses to get involved in national-level nursing advocacy, policy development, and professional growth. Joining the ANA is a suitable choice for a nurse looking to make a national impact in the field of nursing.
Choice D rationale:
The National League for Nursing (NLN) is an organization that primarily focuses on nursing education. While it plays a crucial role in the field of nursing, its focus is more on education and may not align with a nurse's goal to become involved in nursing on a national level from a broader perspective.
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