nurse identify as potentially causing a false-positive result?

The client has a history of breast cancer.

The client takes ibuprofen for headaches.

The client consumed citrus juice 3 days before the test.

The client had a hemorrhoidectomy 1 year ago.

Answer and Explanation

The Correct Answer is B

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Correct Answer is A

Explanation

The correct answer is choice A. The nurse should check the conjunctiva to determine the presence of pallor in a client who is African-American. Choices B, C, and D are incorrect because pallor is not expected in these areas. Choice B is not correct because pallor is not expected in the pinna of the ear. Choice C is not correct because pallor is not expected in the abdomen. Choice D is not correct because pallor is not expected in the antecubital space.

A. Temperature change from 36.6° C (97.8° F) to 38.8° C (101.9° F). B. Respiratory rate change from 12/min to 20/min. C. Blood pressure change from 118/78 mm Hg to 86/50 mm Hg. D. Heart rate change from 110/min to 68/min.

Correct Answer is C

Explanation

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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nurse identify as potentially causing a false-positive result?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is African-American. Which of the following areas should the nurse check to determine the presence of pallor?

Correct Answer is A

Explanation

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?

Correct Answer is C

Explanation

Exhibit 1 Exhibit 2 Graphic Results Temperature 37.9°C (100.2° F) Heart rate 90/min Exhibit 3 Respiratory rate 20/min Blood pressure 140/76 mm Hg A nurse is reviewing the medical record of a client who had a left-sided stroke. Which of the following findings should the nurse expect?

A nurse is providing care for a client who has hemophilia and is bleeding from a small laceration on his arm. After applying a sterile dressing, which of the following actions should the nurse take next?

A nurse has received change-of-shift report for four clients. Which of the following clients should the nurse attend to first?

A nurse in a provider's office is reinforcing teaching about disease prevention with an older adult client. Which of the following immunizations should the nurse recommend to the client?

A nurse is reinforcing teaching with a client about strategies to prevent hypertension. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is reinforcing teaching with a client who has heart failure and a new prescription for furosemide. The nurse should instruct the client to monitor for which of the following adverse effects?

A nurse is collecting data from an older adult client who has a potassium level of 3.2 mEq/L. Which of the following findings should the nurse expect?

Which of the following symptoms should a nurse expect to find when assessing an infant who is dehydrated in an emergency department?