Patient Data

Exhibits

At 2000, the unlicensed assistive personnel (UAP) reported the client's vital signs as a temperature of 102.1° F (38.9° C) orally, a heart rate of 62 beats/minute, respirations of 19 breaths/minute, and a blood pressure of 124/68 mm Hg.

Which action(s) should the nurse take? Select all that apply

Attach the client to a cardiorespiratory monitor to measure the respiratory rate

Assure that the blood pressure cuff is the right size

Alert the healthcare provider once the abnormal finding is confirmed

Retake the temperature orally

Reassess the blood pressure

Measure the heart rate for a full 60 seconds

Answer and Explanation

Correct Answer : C,D,F

A. Attach the client to a cardiorespiratory monitor to measure the respiratory rate: The respiratory rate is within the normal range and does not require continuous monitoring at this stage unless other symptoms suggest deterioration.

B. Assure that the blood pressure cuff is the right size: The blood pressure is within normal limits and does not indicate an issue with the cuff size at this moment.

C. Alert the healthcare provider once the abnormal finding is confirmed: A temperature of 102.1° F (38.9° C) is a significant fever and could indicate worsening infection or an adverse reaction to the medication. Alerting the healthcare provider is essential for prompt evaluation and treatment adjustment.

D. Retake the temperature orally: Confirming the elevated temperature with a retake is crucial for accuracy. Temperature readings can sometimes be affected by factors like improper thermometer use or external influences.

E. Reassess the blood pressure: Blood pressure readings are stable and not indicative of any immediate issue requiring reassessment.

F. Measure the heart rate for a full 60 seconds: The heart rate of 62 beats/minute is on the lower side of normal, and measuring for a full minute will provide a more accurate assessment of the client’s heart rate and detect any irregularities.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. While explaining medications for anxiety is helpful, understanding the client's specific fears is crucial for addressing their concerns effectively.

B. Reviewing the home health care plan is important but should follow addressing the client's immediate concerns and fears about going home.

C. Asking the client about their fears helps to address specific concerns and provides an opportunity to offer targeted support and reassurance.

D. While privacy is important, it is not as critical as understanding and addressing the client's fears directly.

A. Outreach for support group information. B. Blood pressure screening. C. Immunizations that are available. D. Domestic violence assistance.

Correct Answer is C

Explanation

A. Outreach for support groups is more related to secondary or tertiary prevention.

B. Blood pressure screening is a form of secondary prevention, aimed at early detection and intervention.

C. Immunizations are a form of primary prevention, aimed at preventing disease before it occurs.

D. Domestic violence assistance is a crucial service but does not directly relate to primary disease prevention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing discharge instructions for a client who had an above the knee amputation (AKA) and their spouse. The client expresses fear about going home and requests to stay in the hospital one more day. Which intervention is most important for the nurse to implement?

Correct Answer is C

Explanation

The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?

Correct Answer is C

Explanation

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