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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A potassium level of 3.2 mEq/L indicates hypokalemia, which can lead to muscle weakness. Difficulty swallowing, hyperreflexia, and diarrhoea are not typical signs of hypokalemia.

Other choices are not correct because:

B. Difficulty swallowing: Is not a typical sign of hypokalemia.

C. Hyperreflexia: Is not a typical sign of hypokalemia.

D. Diarrhea: Is not a typical sign of hypokalemia.

A. Conjunctiva B. Pinna of the ear C. Abdomen D. Antecubital space

Correct Answer is A

Explanation

The correct answer is choice A. The nurse should check the conjunctiva to determine the presence of pallor in a client who is African-American. Choices B, C, and D are incorrect because pallor is not expected in these areas. Choice B is not correct because pallor is not expected in the pinna of the ear. Choice C is not correct because pallor is not expected in the abdomen. Choice D is not correct because pallor is not expected in the antecubital space.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from an older adult client who has a potassium level of 3.2 mEq/L. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is collecting data from a client who is African-American. Which of the following areas should the nurse check to determine the presence of pallor?

Correct Answer is A

Explanation

A nurse is assisting in the care of a client who had an ischemic stroke. Which of the following observations by the nurse indicates a need for an occupational therapy referral?

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?

A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who has herpes simplex virus type 2. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is collecting data from a female client during an initial health assessment. Which of the following findings should the nurse identify as a risk factor for osteoporosis?

A nurse is reinforcing teaching with a client about strategies to prevent hypertension. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is reinforcing teaching with a client who will undergo a colonoscopy the following week. Which of the following instructions should the nurse include?

A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?