A nurse is caring for a client.
Vital Signs Nurses Notes 1000:
T38.2° C (100.8°F), oral.
BP 114/56 mm Hg, supine HR 99/min
R 32/min
Pulse oximetry 85% on room air (95% to 100%)
1100:
T38.6° C (101.5°F), oral.
BP 112/54 mm Hg, supine Apical HR 108/min
Pulse oximetry 90% on 40% O2 via face mask
Pink mucous membrane is a normal finding.
R 22/min
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T38.6° C (101.5°F), oral.
BP 112/54 mm Hg, supine
Apical HR 108/min
R 22/min
Pulse oximetry 90% on 40% O2 via face mask
Pink mucous membrane is a normal finding.
The Correct Answer is ["A","C","E"]
A. Elevated oral temperature may indicate a fever and requires further assessment.
B. This blood pressure value is within the normal range.
C. An elevated heart rate (108/min) suggests tachycardia, and it requires further investigation to determine the cause.
D. A respiratory rate of 22/min is not a finding that raises concern.
E. A pulse oximetry reading of 90% on supplemental oxygen (40% O2) is below the expected range, indicating potential respiratory distress and requiring immediate attention.
F. Pink mucous membrane is a normal finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Dehydration is more likely to result in an increase, not a drop, in body temperature during exercise.
B. Dehydration can lead to an increased resting heart rate rather than a decrease.
C. Impaired motor control is a potential manifestation of dehydration as it can affect the coordination and function of muscles.
D. Dehydration typically suppresses appetite rather than increasing it.
Correct Answer is A
Explanation
A. Irregular respirations, including Cheyne-Stokes breathing, are common at the end of life.
B. Moist mucous membranes may be a sign of hydration, but in the end-of-life phase, mucous membrane changes are possible, including dryness.
C. Hypertension is less likely in the end-of-life phase; blood pressure tends to decrease.
D. Tachycardia may or may not be present; it can vary depending on the individual's circumstances.
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