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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I can have two glasses of wine with dinner." While moderate alcohol consumption may be acceptable, guidelines typically recommend limiting alcohol intake to one drink per day for women. Two glasses of wine may exceed this recommendation, and excessive alcohol can contribute to higher blood pressure.
B. "I will set my blood pressure goal at 130 over 84." The target blood pressure for individuals with mild hypertension is usually less than 130/80 mmHg. Setting a goal of 130/84 does not meet the recommended guidelines for managing hypertension effectively.
C. "I should exercise for 15 minutes two times per week!" While any exercise is beneficial, the general recommendation for adults is to engage in at least 150 minutes of moderate-intensity aerobic activity each week, which translates to about 30 minutes on most days. Exercising only two times per week for 15 minutes is insufficient for achieving cardiovascular health and blood pressure management.
D. "I should decrease my salt intake to 2 grams per day." Decreasing salt intake to 2 grams per day indicates an understanding of dietary recommendations for managing hypertension. The American Heart Association recommends limiting sodium intake to no more than 2,300 mg per day, and further reduction to 1,500 mg may be beneficial for those with hypertension. Reducing salt can help lower blood pressure effectively.
Correct Answer is C
Explanation
A. Use the arms to pick up heavy items. Lifting heavy objects using only the arms increases strain on the back, worsening pain. Pregnant clients should bend at the knees and lift with their legs while keeping the back straight to reduce stress on the lumbar region.
B. Raise chairs to keep knees lower than hips. Sitting with knees lower than the hips can worsen lumbar lordosis, increasing back discomfort. Instead, knees should be at or slightly above hip level to maintain spinal alignment and reduce strain on the lower back.
C. Perform pelvic rocking exercises several times per day. Pelvic rocking strengthens and stretches lower back muscles, improving flexibility and reducing discomfort. This exercise helps alleviate strain from the growing uterus and supports better posture, decreasing back pain.
D. Sit in a hot tub for 30 min every evening. Prolonged exposure to high temperatures, such as in a hot tub, can cause maternal hyperthermia, increasing the risk of fetal neural tube defects. Warm baths are a safer option to relieve muscle tension without harmful effects.
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