A nurse is obtaining a client's vital signs. Which of the following findings should the nurse report to the charge nurse?

Heart rate 98/min

Temperature 38.0 °C (100.4 °F)

Respiratory rate 14/min

Blood pressure 142/88 mm Hg

Answer and Explanation

The Correct Answer is B

A. Heart rate 98/min. A heart rate of 98 beats per minute is within the normal range for adults, which is typically between 60 and 100 beats per minute. Therefore, this finding does not require reporting.
B. Temperature 38.0 °C (100.4 °F). A temperature of 38.0 °C (100.4 °F) is considered a low-grade fever and may indicate an infection or other underlying condition. This finding should be reported to the charge nurse for further assessment and potential intervention.
C. Respiratory rate 14/min. A respiratory rate of 14 breaths per minute is within the normal range for adults, which is generally between 12 and 20 breaths per minute. This finding does not require reporting.
D. Blood pressure 142/88 mm Hg. A blood pressure reading of 142/88 mm Hg is classified as elevated or stage 1 hypertension. While it is important to monitor blood pressure, this finding may not require immediate reporting unless there are additional concerning symptoms or a significant change from the client's baseline readings.

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Correct Answer is B

Explanation

A. Trousseau's sign indicates hypocalcemia, not hyperkalemia. It is assessed by inflating a blood pressure cuff around the upper arm and observing for muscle spasms in the hand and wrist, which is not related to potassium levels.
B. Irregular heart rate. Hyperkalemia can lead to cardiac dysrhythmias due to its effect on myocardial excitability and conduction. Elevated potassium levels can cause changes in the electrocardiogram (ECG), such as peaked T waves and prolonged PR intervals, which may result in an irregular heart rate and can be life-threatening if not addressed.
C. Hyperactive reflexes are typically associated with conditions such as hypercalcemia or neurological disorders, not hyperkalemia. Hyperkalemia can lead to decreased neuromuscular excitability and may present with muscle weakness or decreased reflexes.
D. Dry mucous membranes is more indicative of dehydration or a fluid volume deficit rather than hyperkalemia. Clients with renal failure may have fluid retention and edema due to impaired kidney function, which is contrary to the presentation of dry mucous membranes.

A. Anterior fontanel closed B. Moves objects to mouth C. Rolls from back to abdomen D. Posterior fontanel closed

Correct Answer is A

Explanation

A. Anterior fontanel closed. The anterior fontanel typically closes between 12 to 18 months of age. Closure at 4 months is premature and may indicate conditions such as craniosynostosis, which can affect skull and brain development. The provider should be notified for further evaluation.
B. Moves objects to mouth. This is an expected developmental milestone for a 4-month-old infant. At this age, infants begin to grasp objects and bring them to their mouths as part of their sensory exploration.
C. Rolls from back to abdomen. Most infants begin rolling from back to abdomen around 5 to 6 months. If a 4-month-old achieves this milestone early, it is not necessarily concerning but rather an indication of advanced motor development.
D. Posterior fontanel closed. The posterior fontanel typically closes between 6 to 8 weeks of age, so closure by 4 months is expected and does not require provider notification.

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A nurse is obtaining a client's vital signs. Which of the following findings should the nurse report to the charge nurse?

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