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 B
Explanation
Choice A rationale
Alendronate should be taken at least 30 minutes before the first food, beverage, or medication of the day with plain water only. This is because other beverages (including mineral water), food, and some medications are likely to reduce the absorption of alendronate.
Choice B rationale
Alendronate should not be taken with milk. This is because the calcium in the milk can bind to the alendronate, preventing it from being absorbed into the body and therefore making it less effective. This is why the patient’s statement indicates a need for further instruction.
Choice C rationale
After taking alendronate, the patient should not lie down and should remain fully upright (sitting, standing, or walking) for at least 30 minutes. This is to help alendronate reach the stomach more quickly and also to reduce the risk of irritation to the esophagus. Therefore, sitting up and reading the morning paper after taking alendronate is a correct practice.
Choice D rationale
Regular bone density tests are necessary while taking alendronate. This is to monitor the drug’s effectiveness in increasing bone mass and to adjust the treatment plan as necessary. Therefore, the patient’s statement is correct.
Correct Answer is ["0.5"]
Explanation
Step 1: The available dose of epinephrine is 0.5 mg in 0.5 mL.
Step 2: The patient needs to administer 0.5 mg of epinephrine.
Step 3: Since the available dose is 0.5 mg/0.5 mL, for 0.5 mg of epinephrine, the patient should be taught to administer 0.5 mL1.
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