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 C

Explanation

A. Remove dentures:

Removing dentures is a step often performed during post-mortem care but may not necessarily need to be completed before family viewing, especially if the dentures are normally worn by the deceased.

B. Apply a shroud around the body with a visible identification tag:

Applying a shroud with a visible identification tag is an important step for dignified covering and identification but might be more appropriate after the family has viewed the body.

C. Clean soiled areas of the body:

This is the most appropriate action to ensure the body appears as dignified and comfortable as possible for family viewing. It involves cleaning any visible soiled areas to provide a respectful presentation to the family.

D. Place the client's head in a dependent position:

Placing the client's head in a dependent position is not typically necessary or recommended in this context. The goal is to ensure the body appears as natural and dignified as possible.

A. Discontinued medications B. Resolved health conditions C. Frequency of vital sign collection D. Completed nursing interventions E. None F. None

Correct Answer is B

Explanation

A. Discontinued medications are documented in the medical record but are not the primary focus of the transfer report.
B. Resolved health conditions should be included in the transfer report so the receiving facility has a clear understanding of the client’s current health status and any changes in care needs.
C. Frequency of vital sign collection is part of ongoing care but is not the most critical information to communicate during transfer.
D. Completed nursing interventions are documented in the record but do not need to be emphasized in the transfer report.

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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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