The nurse is caring for a client who presented to the emergency room with BP of 138/90, HR of 110, O2 Sat of 95%, Temp of 38°C, and abdominal pain level of 7/10. Which of the above vital signs would the nurse address first?
Blood pressure of 138/90
Heart rate 110 beats per minute
O2 Sat of 95%
Temperature 38°C
The Correct Answer is B
A reason:
A blood pressure of 138/90 is elevated but not immediately life-threatening. It is important to monitor, but it is not the highest priority in this situation.
B reason:
A heart rate of 110 beats per minute is the most concerning and should be addressed first. Tachycardia can indicate pain, fever, or other underlying issues that need prompt attention.
C reason:
An O2 Sat of 95% is within normal limits and is not an immediate concern compared to the other vital signs presented.
D reason:
A temperature of 38°C indicates a fever, which needs to be addressed, but the elevated heart rate takes priority as it can have more immediate implications for the client's condition.
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Related Questions
Correct Answer is C
Explanation
The temperature is within the normal range and does not need to be re-measured.
B reason:
The pulse rate is within the normal range and does not need to be re-measured.
C reason:
BP is correct. The blood pressure of 98/58 mm Hg is on the lower side, which may warrant re-measurement to confirm accuracy and assess for potential hypotension.
D reason:
The respiratory rate is within the normal range and does not need to be re-measured.
Correct Answer is B
Explanation
A reason:
Airborne precautions are not necessary for pertussis, as it is not typically spread through airborne particles. These precautions are used for diseases like tuberculosis, which can be transmitted over long distances via air.
B reason:
Droplet precautions are correct. Pertussis, also known as whooping cough, is spread through large respiratory droplets. These droplets can be expelled when an infected person coughs, sneezes, or talks, and they generally travel short distances before settling. Implementing droplet precautions helps prevent the spread of pertussis to other patients and healthcare workers.
C reason:
Protective precautions are used to protect immunocompromised patients from infections, not to prevent the spread of infections like pertussis. They are not applicable in this situation.
D reason:
Contact precautions are used for infections that are spread by direct or indirect contact with the patient or their environment. While important for certain infections, contact precautions alone are insufficient for pertussis, which requires droplet precautions.
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