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.

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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. "I can ask the provider to prescribe a medication that will minimize ." B. "Sitting quietly near the bedside can provide comfort and support." C. "I will call the provider to discuss your concerns." D. "Encourage your partner to wake up to interact with family members."

Correct Answer is B

Explanation

"Sitting quietly near the bedside can provide comfort and support." The nurse's response should provide appropriate comfort and support to the dying client's family, and sitting quietly near the bedside can provide just that.

Options A, C, and D are incorrect because medicating the client to wake them up or to minimize drowsiness is not appropriate as it interferes

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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?

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Naxlex Comprehensive Predictor Exams

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