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.
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Related Questions
Correct Answer is D
Explanation
Ginkgo biloba is a herb that can interact with enoxaparin and increase the risk of bleeding, so the nurse should report its use to the provider. The other options, A (Echinacea), B (Flaxseed powder), and C (Probiotics) do not have any known interactions with enoxaparin, so they do not need to be reported to the provider.
Reasons, why the other choices are not answers, are:
A. Echinacea is a herb that is commonly used to boost the immune system and has not been found to interact with enoxaparin.
B. Flaxseed powder is a dietary supplement that is high in fiber and omega-3 fatty acids and has not been found to interact with enoxaparin.
C. Probiotics are live bacteria that can be found in certain foods or supplements, and they have not been found to interact with enoxaparin.
In summary, the nurse should report the use of Ginkgo biloba to the provider, as it can interact with enoxaparin and increase the risk of bleeding. Echinacea, Flaxseed powder, and Probiotics do not have any known interactions with enoxaparin, so they do not need to be reported to the provider.
Correct Answer is A
Explanation
"Phototherapy." This is a common treatment for psoriasis and involves exposure to ultraviolet light. Choice B is not correct because dermabrasion is not routinely used for the treatment of psoriasis.
Choice C is not correct because benzoyl peroxide is used to treat acne, not psoriasis.
Choice D is not correct because oil-based ointments can actually make psoriasis worse.
Choice B: Dermabrasion is not used to treat psoriasis.
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