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. The nurse is organizing team members to ensure the comprehensive needs of the client are met.
B. A researcher focuses on gathering and analyzing data to contribute to evidence- based practice.
C. An educator provides information and teaching to clients, families, and other healthcare professionals.
D. A counselor offers emotional support and guidance to clients and their families.

A. Case manager B. Respiratory therapist C. Diabetes nurse educator D. Physical therapist E. Occupational therapist F. Enterostomal therapy nurse

Correct Answer is ["B","D","E"]

Explanation

A. Case manager may be involved in coordinating overall care, but based on the current assessment findings, there is a more immediate need for rehabilitation services.
B. A respiratory therapist can help manage the client's oxygen therapy and monitor their lung function.
C. Diabetes nurse educator is not directly relevant to the client's current condition as described.
D. The client's flaccid right upper and lower extremities with decreased muscle tone and strength indicate a need for rehabilitation and physical therapy.
E. The client's difficulty feeding themselves suggests a need for occupational therapy to address activities of daily living (ADLs) and improve independence.
F. Enterostomal therapy nurse is not indicated based on the information provided. The client's issues are primarily related to mobility and activities of daily living.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

A nurse is caring for a client. Exhibits For which of the following interprofessional team members should the nurse anticipate a provider's referral? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

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?

Which of the following is a component of clinical decision-making that the nurse should use to make an evidence-based decision?

A nurse is caring for a client who is experiencing severe nausea and vomiting after a course of chemotherapy. The nurse should monitor the client for which of the following clinical manifestations?

A nurse is monitoring a client who is receiving packed RBCs. The nurse identifies which of the following as an expected finding?

A newly hired nurse is preparing to remove a client's IV catheter. Which of the following actions should the nurse take?

A nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. Which of the following findings should the nurse recognize as a potential causative factor?

A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?