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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A: A nasal cannula provides a low to moderate concentration of oxygen and is not suitable for a client experiencing severe difficulty breathing.
B: A simple face mask provides a higher concentration of oxygen than a nasal cannula but may not deliver a high enough concentration for a client experiencing severe respiratory distress.
C: A Venturi mask can provide a precise and adjustable concentration of oxygen but may not deliver the highest concentration needed in this scenario.
D: A nonrebreather mask can deliver the highest concentration of oxygen (up to 100%) and is the most appropriate choice for a client experiencing severe difficulty breathing.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"E"}
Explanation
The nurse should first review the medications that may be causing the client's confusion, as certain drugs can contribute to altered mental status and should be promptly identified and addressed. After identifying and managing the cause, the nurse should focus on using alternative methods to keep the client safe, ensuring both immediate and long-term patient safety, especially if medication adjustments are required.
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