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 B

Explanation

A. Keep the conversation moving by asking about the client's family: While engaging the client in conversation is important, this statement does not specifically address the client's difficulty in talking about their illness.
B. Let the client know that as their nurse, they are available and willing to listen: Correct. This response demonstrates the nurse's willingness to provide emotional support and active listening. Encouraging the client to express their feelings and concerns about their illness is essential in promoting therapeutic communication.
C. Ask if the client understands what to expect in the advanced stages of the illness: While discussing the client's understanding of their illness is essential, it does not directly address their difficulty in talking to others about it.
D. Ask the client's visitors not to say anything about the advanced disease: This response may hinder communication and restrict the client's opportunity to talk about their feelings and concerns with supportive visitors.

A. Evacuate clients from the area. B. Pull the lever on the fire alarm box. C. Close the fire doors on the unit. D. Use a fire extinguisher to put out the fire.

Correct Answer is A, B, C, D

Explanation

Sequence of Actions:

A: Evacuate clients from the area. This is the first and most crucial step to ensure the safety of all individuals in the vicinity of the fire.

B: Pull the lever on the fire alarm box. Once the immediate area is clear of individuals, the next step is to alert the rest of the building by activating the fire alarm system.

C: Close the fire doors on the unit. This action helps to contain the fire and prevent smoke from spreading to other areas, which can be vital in slowing the fire's progress and safeguarding other parts of the building.

D: Use a fire extinguisher to put out the fire. If the fire is small and contained, and the nurse is trained in its use, a fire extinguisher can be used to douse the flames, preventing further damage.

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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

A client who has advanced cancer tells the nurse that they have a difficult time talking to anyone about the illness. Which of the following actions should the nurse take to encourage therapeutic communication?

Correct Answer is B

Explanation

A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that the nurse should take? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is A, B, C, D

Explanation

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