A nurse is caring for a client with a temperature of 38°C (100.4°F) and a heart rate of 120 beats per minute. Which condition is the client most likely experiencing?

Sepsis.

Hypovolemic shock.

Myocardial infarction.

Pulmonary embolism.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Sepsis is a systemic inflammatory response to infection, often characterized by fever (temperature of 38°C or higher) and tachycardia (heart rate of 120 beats per minute or higher). These symptoms indicate the body’s response to a severe infection.
Choice B rationale
Hypovolemic shock is caused by significant fluid loss, leading to decreased blood volume and perfusion. It typically presents with hypotension and tachycardia, but not necessarily fever.
Choice C rationale
Myocardial infarction (heart attack) is characterized by chest pain, shortness of breath, and other symptoms, but fever and tachycardia are not primary indicators.
Choice D rationale
Pulmonary embolism involves a blockage in the pulmonary arteries, leading to symptoms such as sudden shortness of breath, chest pain, and rapid heart rate, but not typically fever.

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Correct Answer is A

Explanation

Choice A rationale
A blood pressure reading of 180/120 mmHg or higher is indicative of a hypertensive crisis. This condition requires immediate medical attention to prevent damage to vital organs such as the heart, kidneys, and brain.
Choice B rationale
A heart rate of 90 beats per minute is within the normal range and does not indicate a hypertensive crisis. While it is important to monitor heart rate, it is not a definitive sign of a hypertensive emergency.
Choice C rationale
A respiratory rate of 20 breaths per minute is within the normal range and does not indicate a hypertensive crisis. Respiratory rate alone is not a reliable indicator of hypertensive emergencies.
Choice D rationale
A temperature of 37°C (98.6°F) is normal and does not indicate a hypertensive crisis. Body temperature is not a primary indicator of hypertensive emergencies.

A. Decreased breath sounds in the lower lobes. B. Increased respiratory rate and use of accessory muscles. C. Elevated blood pressure and heart rate. D. Presence of wheezing and cyanosis.

Correct Answer is B

Explanation

Choice A rationale
Decreased breath sounds in the lower lobes can indicate areas of the lung that are not ventilating well, but this finding alone does not specifically indicate an exacerbation of COPD. It could be due to other conditions such as pleural effusion or atelectasis.
Choice B rationale
Increased respiratory rate and use of accessory muscles are signs of respiratory distress and indicate that the patient is working harder to breathe. These findings are consistent with an exacerbation of COPD, where the airways are more obstructed, and the patient has difficulty maintaining adequate ventilation.
Choice C rationale
Elevated blood pressure and heart rate can occur in many conditions and are not specific indicators of a COPD exacerbation. These vital sign changes can be due to pain, anxiety, or other stressors.
Choice D rationale
Presence of wheezing and cyanosis are also indicators of a COPD exacerbation. Wheezing indicates airway obstruction, and cyanosis indicates hypoxemia, both of which are common during an exacerbation.

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A nurse is caring for a client with a temperature of 38°C (100.4°F) and a heart rate of 120 beats per minute. Which condition is the client most likely experiencing?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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