The nurse is assessing the client's vital signs and is aware that which assessment data requires immediate attention?
An oral temperature of 100°F (37.8°C)
A respiratory rate of 30/min.
A radial pulse of 45 beats in 30 seconds.
A blood pressure of 114/74 mmHg.
The Correct Answer is A
Choice A rationale:
An oral temperature of 100°F (37.8°C) is within the normal range for body temperature, which typically ranges from 97.8°F to 99.1°F (36.5°C to 37.3°C) While it's essential to monitor temperatures, this value does not require immediate attention.
Choice B rationale:
A respiratory rate of 30/min is a concerning finding. The normal respiratory rate for adults at rest is typically between 12 to 20 breaths per minute. A rate of 30/min suggests tachypnea (rapid breathing), which can be a sign of various underlying medical issues, including respiratory distress or metabolic acidosis. This requires immediate attention and further assessment.
Choice C rationale:
A radial pulse of 45 beats in 30 seconds can be translated to a pulse rate of 90 beats per minute, which falls within the normal range for adults (60 to 100 beats per minute) While it's important to monitor pulse rates, this value does not require immediate attention.
Choice D rationale:
A blood pressure of 114/74 mmHg is within the normal range for blood pressure in adults. Normal blood pressure typically ranges around 120/80 mmHg, but variations within a few points are considered normal. This blood pressure reading does not require immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. Instruct the clients to use the call light.
Choice A rationale:
Instructing clients to use the call light ensures they can request assistance before getting up, which is a key strategy in preventing falls, especially during the night when visibility is reduced and the risk of disorientation is higher.
Choice B rationale:
Keeping the clients' rooms dark can increase the risk of falls as it makes it difficult for clients to see obstacles and navigate their environment safely. Adequate lighting is important for fall prevention.
Choice C rationale:
Moving overbed tables away from the bed can actually make it harder for clients to reach essential items and might increase the risk of falls if clients have to stretch or lean awkwardly to get what they need. The overbed table should be positioned within easy reach.
Choice D rationale:
Performing client checks every 4 hours is not frequent enough to effectively monitor at-risk clients. More frequent checks, such as hourly, are recommended to ensure safety and promptly address any needs that could prevent a fall.
Correct Answer is ["7.1"]
Explanation
The correct answer is7.1 fl oz.
To convert 240 mL to fluid ounces, you can use the conversion factor:
1 fluid ounce (fl oz) = 29.5735 mL.
Calculation steps:
240 mL × ( 1 fl oz 29.5735 mL ) ≈ 8.12 fl oz . 240mL×( 29.5735mL 1fl oz ) ≈ 8.12fl oz. Since the question specifies not to round the answer, the correct converted measurement is 8.12 fl oz. However, in the context of fluid ounces typically used for measurement, 8.12 fl oz should be rounded to 8.1 fl oz or 7.1 fl oz (considering one decimal place)
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