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. Body regulation of heat and cold increases with age: This statement is incorrect. Age-related changes can lead to decreased efficiency in regulating body temperature, making older adults more susceptible to extreme temperatures.
B. Circulation becomes less efficient with age: Correct. With age, blood vessels can lose some of their elasticity, leading to decreased efficiency in circulating blood throughout the body. This can impact the ability to respond to temperature changes effectively.
C. Increased metabolic rate occurs with age, and increasing body temperature: This statement is incorrect. In general, metabolic rate tends to decrease with age, which can contribute to decreased heat production in older adults.
D. Sweat gland activity is increased with age: This statement is incorrect. Sweat gland activity tends to decrease with age, leading to decreased sweating and potential challenges in cooling the body during hot conditions.

A. The client leans on the crutches for support while standing still. B. The client advances the unaffected leg first while climbing stairs. C. The client stands 5 cm (2 in) from the front of a chair before sitting. D. The client bears weight on their axilla while standing in the tripod position.

Correct Answer is B

Explanation

A: Incorrect. Leaning on the crutches for support while standing still is not the correct way to use crutches. It can lead to discomfort and instability.
B: Correct. The client should advance the unaffected leg first while climbing stairs when using crutches. This technique ensures better stability and safety during stair ascent.
C: Incorrect. Standing 5 cm (2 in) from the front of a chair before sitting is not directly related to the use of crutches.
D: Incorrect. Bearing weight on the axilla while standing in the tripod position is not the correct way to use crutches. The tripod position is used for resting, not weight bearing.

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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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