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 A
Explanation
A. With a potassium level of 5.2 mEq/L, the client is not in need of additional potassium, and it is appropriate to notify the physician to discuss potential adjustments to the prescription.
B. Verifying the results with the lab may provide confirmation but does not address the need for action.
C. Omitting the KCL dose is appropriate in this situation as the client's potassium level is within the normal range.
D. Giving the ordered KCL as prescribed is not appropriate in this case, as the client's potassium level is already within the normal range.
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.
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