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.

Nursing Test Bank

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Correct Answer is B

Explanation

A. While cold packs might be used for certain conditions, measuring the circumference of both upper arms is the priority in this situation.
B. Swelling of the arm above the PICC insertion site can indicate a complication such as thrombophlebitis, which is inflammation and clotting of the vein. The nurse should measure the circumference of both upper arms and compare them to detect any difference in size, which can indicate edema due to impaired venous return. This is the first action the nurse should take because it is an assessment step that can provide objective data to guide further interventions.
C. Swelling above the PICC insertion site could indicate complications such as infiltration, and the provider needs to be informed promptly. However, the nurse should first measure the circumference of both upper arms first.
D. Removing the PICC line should be done under the guidance of a healthcare provider, and it is not the first action to take.

A. Hyperactive reflexes B. Hyperactive bowel sounds C. Weak, irregular pulse D. Extreme thirst

Correct Answer is C

Explanation

A: Hypokalemia is associated with hypoactive reflexes, not hyperactive reflexes.
B: Hyperactive bowel sounds are more indicative of hyperkalemia, not hypokalemia.
C: Weak, irregular pulse is a common manifestation of hypokalemia and reflects the impact of potassium on cardiac function.
D: Extreme thirst is not a typical symptom of hypokalemia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is caring for a client who is unconscious and has a living will. The client's family asks if they can make changes to lifesaving measures now that the client is unconscious. Which of the following statements should the nurse make?

A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?

A nurse is assessing a client who has diarrhea. Which of the following findings is a manifestation of hypokalemia?

A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

A nurse is assessing an older adult client who is receiving IV therapy. The nurse should recognize that which of the following findings indicates fluid volume excess? (Select all that apply.)

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 caring for a client who had total thyroidectomy and a serum calcium level of 7.6 mg/dL. Which of the following findings should the nurse expect?

A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is effectively responding to treatment?