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.
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. Hyponatremia (low sodium) can lead to neurological symptoms, including nausea and vomiting.
B. Extreme thirst is more commonly associated with hypernatremia (high sodium).
C. Flushed skin and fever are not typical manifestations of hyponatremia.
D. Fever is not a typical manifestation of hyponatremia.
Correct Answer is D
Explanation
A. Hyperactive bowel sounds are associated with hyperkalemia, not hypokalemia.
B. Hypertension is not typically associated with hypokalemia. In fact, hypokalemia is more likely to be associated with hypotension.
C. Cerebral edema is not a common manifestation of hypokalemia; it is more commonly associated with conditions like hyponatremia.
D. Muscle weakness is a classic manifestation of hypokalemia. Potassium is crucial for proper muscle function, and a deficiency can lead to weakness.
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