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

Click to highlight the findings at 1100, that require follow-up. To deselect a finding, click on the finding again.

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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Lethargy is a common manifestation of respiratory acidosis due to the buildup of carbon dioxide leading to respiratory depression.
B. Numbness of fingers is more associated with respiratory alkalosis.
C. Dry skin is not a direct manifestation of respiratory acidosis.
D. Abdominal pain is not typically associated with respiratory acidosis.

A. Dry, sticky mucous membranes B. Muscle tremors C. Polyuria D. Negative Chvostek's sign

Correct Answer is B

Explanation

A. Dry, sticky mucous membranes are associated with dehydration, not low calcium levels.
B. Muscle tremors are a potential manifestation of hypocalcemia.
C. Polyuria is not typically associated with low calcium levels.
D. Chvostek's sign is a facial twitching that can be associated with hypocalcemia; a negative Chvostek's sign would not be expected in this case.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is assessing a preschooler who has a calcium level of 8.0 mg/dL. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGS? pH 7.22 PaCO2 68 mm Hg Base excess-2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L

A nurse is preparing to administer potassium chloride (KCL) to a client who is receiving diuretic therapy. The nurse reviews the client's serum potassium level results and discovers the client's potassium level is 3.2 mEq/L. Which of the following actions should the nurse take?

A nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 mEq PO daily. The nurse reviews the client's most recent laboratory results and finds the client's potassium level is 5.2 mEq/L. Which of the following actions should the nurse take?

A nurse is organizing interprofessional team members to meet the needs of a client. Which of the following roles is the nurse taking?

A nurse is instructing a group of clients regarding calcium rich foods. Which of the following foods should the nurse include in the teaching as the best source of calcium?

A nurse is preparing to administer 2 units of packed RBCs to an older adult client. Which of the following actions should the nurse take?

A nurse is assessing a client who has fluid volume deficit. The nurse should expect which of the following findings?