The unlicensed assistive personnel (UAP) recorded the vital signs of four clients. Which client needs immediate nursing intervention? (SEE HANDOUT- PRIORITY VITAL SIGNS)
B
A
D
C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Ask the client to take deep breaths. Deep breathing can help relax the anal sphincter, but if resistance is already encountered, forcing the thermometer further could cause injury.
B. Remove the thermometer and reinsert more forcefully. Forcing the thermometer can cause damage to the rectal mucosa, leading to pain, bleeding, or even perforation.
C. Apply mild pressure to advance. Any resistance suggests a possible obstruction, such as stool or anatomical issues. Applying pressure could cause harm, so the thermometer should not be advanced further.
D. Remove the thermometer immediately. If resistance is encountered, the safest action is to withdraw the thermometer to prevent injury. The nurse should reassess the situation and consider alternative temperature measurement methods.
Correct Answer is D
Explanation
A. "Don't worry. The cancer prevents you from becoming addicted." This statement is incorrect because having cancer does not prevent addiction. However, appropriate pain management in patients with severe pain does not typically lead to addiction.
B. "That is a valid worry. I wouldn't want to become addicted." While acknowledging the patient’s concern is important, this response reinforces fear rather than providing reassurance based on medical evidence.
C. "My cousin was addicted to pain killers when he had cancer." This response is inappropriate because it is anecdotal and does not address the patient’s concern with factual medical information.
D. "Because you have severe pain, the medication is necessary. There is little chance of addiction as long as you take the medication as prescribed." This is the best response because it reassures the patient that pain control is a priority and that, when used correctly, the risk of addiction is minimal.
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