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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A gastric residual volume of 10ml is not considered high. The client is receiving 60ml/hr of feeding, which is within normal limits. Therefore, the nurse should continue the feeding as ordered.

A. Bananas B. White rice C. Cabbage D. Cheddar cheese

Correct Answer is A

Explanation

Choice A rationale
Bananas are a rich source of potassium. For a patient taking furosemide (a diuretic that can cause loss of potassium) and with a low serum potassium level, incorporating bananas into their diet can help increase their potassium levels.
Choice B rationale
White rice is not a significant source of potassium. It would not be the best choice for a patient needing to increase their potassium levels.
Choice C rationale
While cabbage does contain some potassium, it is not as high in potassium as other foods, such as bananas.
Choice D rationale
Cheddar cheese is not a significant source of potassium. It would not be the best choice for a patient needing to increase their potassium levels.

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Given the following vital signs, which should the nurse address first in the patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

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