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 B
Explanation
A. A decrease in systolic blood pressure is not directly related to dehydration.
Dehydration is more associated with fluid balance.
B. With aging, there is a natural decline in kidney function, including a decrease in the ability to concentrate urine. This can contribute to an increased risk of dehydration.
C. An increase in saliva production is not typically associated with dehydration.
D. With aging, there is actually a decrease in the percentage of body water, making older adults more susceptible to dehydration.
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.
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