The unlicensed assistive personnel (UAP) recorded the vital signs of four clients. Which client needs immediate nursing intervention? (SEE HANDOUT- PRIORITY VITAL SIGNS)

Exhibits

Answer and Explanation

The Correct Answer is C

Client A has normal vital signs except for a mild fever, no urgent intervention needed.

Client B shows mild tachycardia and increased respiratory rate, but oxygen saturation and blood pressure remain stable, requires monitoring but not immediate action.

Client C has fever, tachycardia, and tachypnea, suggesting infection or dehydration. While assessment is needed, the patient is not in immediate distress compared to Client D.

Client D requires immediate nursing intervention due to the following critical findings: Bradycardia which may indicate poor perfusion, conduction abnormalities, or medication side effects, bradypnea can signal respiratory depression or impending failure, hypotension suggests shock or decreased perfusion, which may lead to organ failure and hypoxia, oxygen saturation below 90% is a critical finding and requires immediate intervention.

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Correct Answer is D

Explanation

A. "The PCA will give additional pain medication whenever the button is pushed." PCA pumps have lockout intervals to prevent overdose, so pushing the button repeatedly will not always result in additional medication.
B. "Wait until the pain becomes severe before pushing the PCA button." PCA is most effective when used at the onset of pain rather than waiting until it becomes severe, which can make pain harder to control.
C. "The PCA will deliver medication through the IV until the pain is all gone." PCA provides controlled doses of medication but does not eliminate pain entirely. The goal is pain management, not complete pain relief.
D. "You or a designated family member are the only one who gets to push the PCA button—nobody else may do so." PCA is designed for patient-controlled use, and only the patient (or a designated, trained family member in special cases) should operate it to ensure proper dosing and safety.

A. Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities B. Progressive atrophy of the intramuscular calf veins, causing venous insufficiency C. Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure D. Hormonal changes causing vasodilation and a resulting drop in blood pressure

Correct Answer is C

Explanation

A. Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities. The inferior vena cava does not significantly narrow with aging. Varicosities are more commonly due to valve insufficiency in the veins rather than vena cava narrowing.
B. Progressive atrophy of the intramuscular calf veins, causing venous insufficiency. Venous insufficiency is common in older adults, but it is primarily due to valve dysfunction and prolonged venous pressure rather than atrophy of calf veins.
C. Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure. Aging leads to arteriosclerosis, where blood vessels become stiffer, reducing their ability to expand and contract, which contributes to increased systolic blood pressure. This is a well-documented normal physiologic change in older adults.
D. Hormonal changes causing vasodilation and a resulting drop in blood pressure. While some hormonal changes occur with aging, they do not typically lead to significant vasodilation. In fact, the loss of vascular elasticity and autonomic dysfunction can contribute to postural hypotension, but not a generalized drop in blood pressure.

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The unlicensed assistive personnel (UAP) recorded the vital signs of four clients. Which client needs immediate nursing intervention? (SEE HANDOUT- PRIORITY VITAL SIGNS) Exhibits

Nursing Test Bank

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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The unlicensed assistive personnel (UAP) recorded the vital signs of four clients. Which client needs immediate nursing intervention? (SEE HANDOUT- PRIORITY VITAL SIGNS)

Exhibits