An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 88/58 mm Hg. Which of the following vital signs should the nurse re-measure?

Respiratory rate.

Temperature.

Pulse rate.

BP.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Re-measuring the respiratory rate is unnecessary. The reported respiratory rate falls within the normal range of 12-20 breaths per minute for adults.

Choice B rationale:

Re-measuring the temperature is the correct action. Tympanic temperature measurements can be influenced by factors such as earwax buildup, ear infection, or improper placement of the thermometer. Repeating the temperature measurement ensures accuracy.

Choice C rationale:

Re-measuring the pulse rate is unnecessary. The reported pulse rate of 92 beats per minute falls within the normal range of 60-100 beats per minute for adults.

Choice D rationale:

Re-measuring the blood pressure is unnecessary. The reported blood pressure of 88/58 mm Hg, while at the lower end of the normal range (typically around 90/60 mm Hg), is not excessively low and doesn't indicate an immediate need for concern.

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 D

Explanation

Choice A rationale:

Decreased heart rate is not an anticipated finding in response to acute pain. Pain typically triggers sympathetic nervous system activation, leading to an increased heart rate as a physiological response to the stressor.

Choice B rationale:

Hyperactive bowel sounds are not typically associated with acute pain. Acute pain is more likely to induce a sympathetic response, which can lead to decreased gastrointestinal motility and hypoactive bowel sounds.

Choice C rationale:

Decreased blood pressure is not a common response to acute pain. Pain often leads to an increase in blood pressure due to the activation of the sympathetic nervous system and the release of stress hormones.

Choice D rationale:

Increased respiratory rate is the anticipated finding in response to acute pain. Acute pain can cause an increase in the sympathetic nervous system activity, leading to a higher respiratory rate as the body prepares for a fight-or-flight response. This increased respiratory rate helps oxygenate the blood and meet the potential increased demand for energy during stress.

A. Dyspnea. B. Clubbing of the fingers. C. Deep respirations. D. Bradycardia. E. Barrel chest.

Correct Answer is ["A","B","E"]

Explanation

Choice A rationale:

Dyspnea (shortness of breath) is a common finding in clients with emphysema. Emphysema is a chronic obstructive pulmonary disease characterized by the destruction of lung tissue, leading to reduced lung elasticity and airflow limitation, which can result in difficulty breathing.

Choice B rationale:

Clubbing of the fingers is another expected finding in clients with advanced emphysema. Clubbing is the swelling and rounding of the fingertips, often associated with chronic respiratory conditions. It is thought to be a result of chronic hypoxia and inadequate oxygenation.

Choice C rationale:

Deep respirations are not typically associated with emphysema. Clients with emphysema often exhibit shallow, rapid respirations due to the loss of lung tissue elasticity, which impairs the normal respiratory mechanics.

Choice D rationale:

Bradycardia (slow heart rate) is not a common finding in emphysema. Emphysema primarily affects the respiratory system and does not directly influence heart rate. Bradycardia could be related to other factors but is not a characteristic finding of emphysema.

Choice E rationale:

Barrel chest is a classic physical finding in clients with emphysema. It results from the hyperinflation of the lungs due to the trapping of air in the damaged alveoli. This gives the chest a rounded appearance, similar to the shape of a barrel.

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

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 88/58 mm Hg. Which of the following vital signs should the nurse re-measure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who reports acute pain. The nurse should anticipate which of the following findings?

Correct Answer is D

Explanation

A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to see in this client? (Select all that apply.).

Correct Answer is ["A","B","E"]

Explanation

A Cardiovascular nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?

A patient has difficulty in breathing. The nurse provides oxygen therapy to the patient, after which the patient feels better. Which principle is involved in this situation?

A Medical-Surgical nurse is assessing a client's heart sounds. In which of the following points of auscultation would the nurse hear the S2 sound most clearly?

A nurse is admitting a client who has measles and a persistent cough. Which of the following actions is a priority for the nurse to take?

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

A patient is given lorazepam, a benzodiazepine, to decrease symptoms of anxiety and restlessness on the evening prior to planned surgery. The nurse knows that the patient is experiencing a paradoxical drug reaction when which of the following is assessed?