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 A
Explanation
A. A urine specific gravity of 1.020 indicates a concentration within the normal range, suggesting that the kidneys are effectively conserving water and concentrating urine, which is a positive response to fluid therapy.
B. A sodium level of 165 mEq/L is elevated and may indicate hypernatremia, which could be a sign of inadequate water intake or excess sodium.
C. Hct (hematocrit) of 62% may indicate hemoconcentration and is not a specific marker for fluid status.
D. A potassium level of 5.2 mEq/L is within the normal range and is not a specific indicator of the effectiveness of fluid resuscitation.
Correct Answer is C
Explanation
A. This is more related to psychological changes rather than physiological changes in older adults.
B. Bedwetting is not a typical physiological change in older adults. It is more commonly associated with children.
C. Older adult clients might experience changes in their appetite and metabolism that can lead to overeating and obesity. This can increase the risk of chronic diseases such as diabetes, hypertension, and cardiovascular problems.
D. While emotional changes may occur, the term "feelings" is too broad. Physiological changes are more specific to bodily functions.
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