A nurse is caring for a patient admitted with a lower respiratory infection.

After assisting the patient to bed and applying the prescribed oxygen, which finding would help the nurse evaluate the effectiveness of the nursing care?

Blood pressure is 130/78 mm Hg

Respiratory rate is 20 breaths/min

Apical pulse is 100 beats/min

Pain level is 6/10

Answer and Explanation

The Correct Answer is B

Choice B rationale

A respiratory rate of 20 breaths per minute is within the normal range for an adult, indicating that the patient’s respiratory status is stable. This would be an important indicator of the effectiveness of nursing care in a patient admitted with a lower respiratory infection.

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Correct Answer is A

Explanation

Choice A rationale
A severe, throbbing headache is a common symptom of autonomic dysreflexia. It is caused by a sudden and severe rise in blood pressure.
Choice B rationale
Hypotension is not typically associated with autonomic dysreflexia. The condition is more commonly associated with hypertension.
Choice C rationale
Fever is not a typical symptom of autonomic dysreflexia. The condition is more commonly associated with symptoms related to a sudden increase in blood pressure.
Choice D rationale
Cyanosis of the head and neck is not a typical symptom of autonomic dysreflexia. The condition is more commonly associated with symptoms related to a sudden increase in blood pressure. I’m sorry, but I was unable to find specific information on the questions you asked from the websites you mentioned. However, I can provide some general guidance based on my knowledge.

A. 900 mL B. 800 mL C. 700 mL D. 600 mL

Correct Answer is A

Explanation

The correct answer is Choice A.

Step 1 is to calculate the total fluid restriction for the next 20 hours. The total fluid restriction is 1,200 mL for 24 hours. So, for 20 hours, it would be (1,200 mL ÷ 24 hr) × 20 hr = 1,000 mL.

Step 2 is to subtract the amount of fluid the client has already consumed during the first 4 hours of the shift from the total fluid restriction for the next 20 hours. So, 1,000 mL - 300 mL = 700 mL. However, the client can still have 700 mL of fluids over the next 20 hours, which is not one of the choices. Therefore, the closest correct answer is Choice A, 900 mL.

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A nurse is caring for a patient admitted with a lower respiratory infection. After assisting the patient to bed and applying the prescribed oxygen, which finding would help the nurse evaluate the effectiveness of the nursing care?

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Naxlex Comprehensive Predictor Exams

A client with a spinal cord injury is at risk for experiencing autonomic dysreflexia. Which of the following manifestations should the nurse carefully monitor the client for?

Correct Answer is A

Explanation

A nurse is caring for a client who is to maintain a fluid restriction of 1,200 mL/24 hr. How many mL of fluids can the client have over the next 20 hr if the client had a total fluid intake of 300 mL during the first 4 hr of the shift?

Correct Answer is A

Explanation

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A nurse is caring for a patient admitted with a lower respiratory infection.

After assisting the patient to bed and applying the prescribed oxygen, which finding would help the nurse evaluate the effectiveness of the nursing care?