A nurse is reviewing vital signs obtained by an assistive personnel on a group of clients. The previous vital signs for each of the clients were obtained 4 hours earlier. Which of the following changes should the nurse identify as the priority finding?
Temperature change from 36.6° C (97.8° F) to 38.8° C (101.9° F).
Respiratory rate change from 12/min to 20/min.
Blood pressure change from 118/78 mm Hg to 86/50 mm Hg.
Heart rate change from 110/min to 68/min.
The Correct Answer is C
The correct answer is choice C: Blood pressure change from 118/78 mm Hg to 86/50 mm Hg.
Choice C rationale: A significant drop in blood pressure can indicate various serious conditions, such as shock, hemorrhage, or a severe infection. The nurse should assess the client further and intervene as necessary to prevent complications.
Choice A rationale: The change in temperature may indicate the onset of a fever and requires further assessment, but it is not as immediately concerning as the sudden drop in blood pressure.
Choice B rationale: The change in respiratory rate could be a result of factors like pain, anxiety, or exercise. While it warrants further assessment, it is not as critical as the blood pressure change.
Choice D rationale: The heart rate change may be a response to medications, rest, or other factors. It should be monitored and assessed, but the priority finding is the blood pressure change, which may indicate a more severe underlying issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B: Store opened insulin vials at room temperature for up to 4 weeks.
Choice B rationale: Opened insulin vials can be stored at room temperature (59°F to 86°F or 15°C to 30°C) for up to 4 weeks. After this period, the insulin may lose potency, and a new vial should be used.
Choice A rationale: Regular insulin is short-acting, and its peak effect occurs 2 to 3 hours after administration. Eating a snack 6 hours after insulin administration may not be necessary as the insulin would have already reached its peak effect, and blood glucose levels should be monitored accordingly.
Choice C rationale: Warming the insulin vial to dissolve crystals is not recommended. Insulin should be inspected before use, and if crystals or clumps are present, it should be discarded as this could indicate that the insulin has lost its effectiveness.
Choice D rationale: Unopened insulin vials should be stored in the refrigerator (36°F to 46°F or 2°C to 8°C) and should not be frozen. Freezing can cause insulin to lose potency or become ineffective. Once opened, insulin vials can be stored at room temperature for up to 4 weeks, as mentioned in choice B.
Correct Answer is A
No explanation
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