A nurse is collecting data on four clients. Which of the following findings should the nurse report to the provider?

Heart rate 62/min

Urine output of 200 mL per 8 hr

Pulse oximetry 95% on room air

BP 112/76 mm Hg

Answer and Explanation

The Correct Answer is B

A.   Heart rate 62/min: A heart rate of 62 beats per minute is within the normal range for many adults and may not require immediate reporting unless it is a significant change from the client's baseline.
B.   Urine output of 200 mL per 8 hr: Correct. A urine output of 200 mL in 8 hours is considered low and may indicate inadequate kidney perfusion or function. It should be reported to the provider as it could be a sign of renal impairment or dehydration.
C.   Pulse oximetry 95% on room air: A pulse oximetry reading of 95% on room air is within the normal range for oxygen saturation in most healthy individuals. It does not require immediate reporting unless the client has a specific condition or baseline that warrants concern.
D.   BP 112/76 mm Hg: Blood pressure of 112/76 mm Hg is within the normal range for many adults and may not require immediate reporting unless there are specific concerns related to the client's medical history or condition.

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Correct Answer is A

Explanation

A: Correct. Applying thromboembolic stockings (compression stockings) to the client's legs is a task that can be safely delegated to assistive personnel. The nurse should provide clear instructions on how to apply them properly.
B: Incorrect. Monitoring the circulation in all four extremities requires clinical judgment and skilled assessment, and it should not be delegated to assistive personnel.
C: Incorrect. Recording the condition of the client's skin requires observation and assessment, which should not be delegated to assistive personnel.

A. Volunteer at the local food pantry B. Attend an exercise program C. Find an enjoyable hobby D. Support environmental conservation

Correct Answer is B

Explanation

A: While volunteering at a local food pantry can be a meaningful activity, it is not the priority when considering Maslow's hierarchy of needs. Physiological needs, such as nutrition and exercise, take precedence.
B: Correct. Attending an exercise program addresses the client's physiological needs (specifically the need for physical activity and health) and takes priority over other options in this context.
C: Finding an enjoyable hobby addresses the client's need for self-fulfillment and self-esteem, which comes at a higher level in Maslow's hierarchy. It is not the immediate priority during discharge planning.
D: Supporting environmental conservation aligns with self-actualization, which is a higher-level need in Maslow's hierarchy. It is not the priority during discharge planning.

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A nurse is collecting data on four clients. Which of the following findings should the nurse report to the provider?

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Naxlex Comprehensive Predictor Exams

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