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. Check that the restraint is tied to a fixed frame of the bed: Restraints should never be tied to the side rails or a fixed frame of the bed, as this can lead to serious injuries. Restraints should be secured to the bed frame using quick-release ties to ensure safety.
B. Pad bony prominences on the wrist: Correct. Padding bony prominences on the wrist is an important step in the use of restraints to prevent skin breakdown and pressure injuries.
C. Remove the restraint every 4 hr to allow movement: While repositioning and releasing restraints periodically is essential for the client's comfort and safety, it is not appropriate to remove wrist restraints entirely every 4 hours, as they were prescribed for a specific purpose.
D. Tie the restraint with a knot that will tighten when pulled: Restraints should never be tied with a knot that can tighten when pulled, as this can cause harm to the client and restrict blood flow. Restraints should be secured using quick-release ties to allow for easy removal in
emergencies.

A. "Keep your knees in a locked position when standing for prolonged periods." B. "Bend at the waist when lifting a heavy object." C. "Keep your feet close together when lifting a heavy object." D. "When lifting a heavy object, keep it close to your body."

Correct Answer is D

Explanation

A. "Keep your knees in a locked position when standing for prolonged periods." This instruction is incorrect. Keeping knees locked can lead to muscle fatigue and increased risk of injury during prolonged standing.
B. "Bend at the waist when lifting a heavy object." This instruction is incorrect. Bending at the waist during lifting can strain the lower back and increase the risk of back injuries.
C. "Keep your feet close together when lifting a heavy object." This instruction is incorrect.
Keeping feet close together can make the base unstable and increase the risk of falling or losing balance during lifting.
D. "When lifting a heavy object, keep it close to your body." Correct. Keeping the heavy object close to the body while lifting helps reduce strain on the back and minimizes the risk of injury. This technique allows the body's core muscles to better support the weight.

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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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