Given the following vital signs, which should the nurse address first in the patient?
Blood pressure 118/76 mm Hg, heart rate 92/min, temperature 38.1° C (100.6° F), oxygen saturation 95% on room air.
Blood pressure 126/84 mm Hg, heart rate 104/min, respiratory rate 24/min, temperature 38.5 C (101.3* F), oxygen saturation 92% on room air.
The Correct Answer is B
Choice A rationale
The vital signs presented in this choice are within the normal range. A blood pressure of 118/76 mm Hg is considered normal. A heart rate of 92/min is slightly elevated but still within the normal range (60-100 beats per minute). A temperature of 38.1° C (100.6° F) indicates a slight fever, which could be a response to an infection or inflammation. An oxygen saturation of 95% on room air is within the normal range (95%-100%).
Choice B rationale
The vital signs presented in this choice indicate that the patient may be experiencing a respiratory issue. A blood pressure of 126/84 mm Hg is slightly elevated but still within the acceptable range. A heart rate of 104/min is high, indicating that the heart is working harder than normal. A respiratory rate of 24/min is also high, suggesting that the patient may be having difficulty breathing. A temperature of 38.5 C (101.3* F) indicates a fever, which could be a response to an infection. An oxygen saturation of 92% on room air is below the normal range (95%-100%), suggesting that the patient is not getting enough oxygen. This is the vital sign that should be addressed first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Contractures, or the shortening and hardening of muscles, tendons, or other tissue, can be a complication of burns. However, they are not typically the primary risk for a patient with burns on the head, neck, and chest.
Choice B rationale
While fluid imbalance can occur with any burn due to loss of fluid from the damaged skin, it is not typically the primary risk for a patient with burns on the head, neck, and chest.
Choice C rationale
Airway obstruction is a primary risk for a patient with burns on the head, neck, and chest. Swelling from the burns can lead to obstruction of the airway, making it difficult for the patient to breathe.
Choice D rationale
While infection is a risk with any burn, it is not typically the primary risk for a patient with burns on the head, neck, and chest. The primary risk is airway obstruction due to swelling from the burns.
Correct Answer is D
Explanation
Choice A rationale
While fatigue is a common symptom of Hodgkin’s disease, it is not the most urgent symptom to address when there is significant cervical lymph node enlargement.
Choice B rationale
Pain can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
Choice C rationale
Fever can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
Choice D rationale
Stridor is a high-pitched, wheezing sound caused by disrupted airflow. Stridor may indicate a serious condition affecting the throat or larynx (voice box). With significant cervical lymph node enlargement, the lymph nodes may be pressing on the airway, causing stridor. This is a medical emergency and should be addressed first.
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