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, a client who had abdominal surgery 2 days ago and the incision line is separating. This client requires immediate attention as a separating incision can indicate wound dehiscence or evisceration, which are surgical emergencies. Choice A is incorrect because although C. difficile is a serious infection, liquid stools are a common symptom and do not require immediate attention. Choice C is incorrect because intermittent coughing up clear sputum is a normal finding for a client with a tracheostomy, and does not indicate a change in the client's condition. Choice D is incorrect because the client fell 12 hours ago and reports pain as 4 on a scale of 0 to 10, which indicates a low level of pain.
Choice A: A client who has Clostridium difficile and has liquid stools is incorrect because although C. difficile is a serious infection, liquid stools are a common symptom and do not require immediate attention.
Choice C: A client who has a chronic tracheostomy and is intermittently coughing up clear sputum is incorrect because intermittent coughing up clear sputum is a normal finding for a client with a tracheostomy, and does not indicate a change in the client's condition.
Choice D: A client who fell 12 hours ago and reports pain as 4 on a scale of 0 to 10 is incorrect because the level of pain is low and does not require immediate attention.
Correct Answer is C
Explanation
Choice A rationale: Breast self-examinations should be performed monthly, not every other month. This regularity helps with early detection of any changes.
Choice B rationale: Dimpling of the skin on the breasts is not common and can be a sign of breast cancer or other conditions. This statement indicates a misunderstanding.
Choice C rationale: It is indeed common for one breast to be slightly larger than the other. This is a normal variation and not usually a cause for concern.
Choice D rationale: Breast self-examinations should be performed several days after the menstrual period ends, not the day the period begins. This timing helps to reduce the likelihood of hormonal changes affecting breast tissue.
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