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. Dark-colored urine is a common finding in dehydration, indicating concentrated urine.
B. Dehydration is more likely to be associated with hypotension rather than high blood pressure.
C. Distended neck veins are more associated with fluid overload, not dehydration.
D. Moist skin is not a typical finding in dehydration; dry skin is more common.

A. Hypercalcemia B. Hypovolemia C. Hyperglycemia D. Hypokalemia

Correct Answer is C

Explanation

A: Dextrose 10% in water does not contain calcium, so hypercalcemia is not a concern.
B: Dextrose 10% in water provides hydration and is not associated with hypovolemia.
C: Dextrose is a form of sugar, and its infusion can lead to increased blood glucose levels (hyperglycemia).
D: Dextrose 10% in water does not affect potassium levels, so hypokalemia is not a concern.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

A nurse is caring for a client who is receiving an IV infusion of dextrose 10% in water. The nurse should monitor the client for which of the following adverse effects?

Correct Answer is C

Explanation

A nurse is assessing a client who has a sodium level of 116 mEq/L. Which of the following findings should the nurse expect?

A nurse is teaching a class about the steps of critical thinking. The nurse should include that interpreting data is included in which of the following steps?

A nurse is assessing a client who is at the end of life. Which of the following findings should the nurse expect?

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 assessing a client who is experiencing hypervolemia. Which of the following findings should the nurse expect?

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 assessing an older adult client who is experiencing age-related changes. Which of the following findings should the nurse expect?

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?