Which client assessment should a nurse immediately report to the health care provider?
Report of joint pain by a client who recently started taking arthritis medication.
Report of decreased appetite and difficulty sleeping in a recently widowed client.
Weight loss of two pounds in a client admitted in congestive heart failure.
Diminished breath sounds in a client admitted with pneumonia.
The Correct Answer is D
This is because diminished breath sounds indicate poor oxygenation and ventilation, which can lead to respiratory failure and hypoxia. The healthcare provider should be notified immediately to assess the client and provide appropriate interventions.
Choice A is wrong because joint pain is a common side effect of some arthritis medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs). It does not require immediate attention unless it is severe or accompanied by other symptoms, such as swelling, redness, or fever.
Choice B is wrong because decreased appetite and difficulty sleeping are normal responses to grief and loss. They do not indicate a medical emergency, but rather a need for emotional support and counseling.
Choice C is wrong because a weight loss of two pounds in a client admitted with congestive heart failure is a positive sign that indicates fluid removal and improved cardiac function. It does not require immediate reporting, but rather ongoing monitoring and evaluation.
Normal ranges for vital signs are as follows :
- Blood pressure: 90/60 mm Hg to 120/80 mm Hg
- Breathing: 12 to 18 breaths per minute
- Pulse: 60 to 100 beats per minute
- Temperature: 97.8°F to 99.1°F (36.5°C to 37.3°C); average 98.6°F (37°C)
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is because the resident is independent and sociable, and has the right to choose her own grooming preferences.
Serving her breakfast in her room will respect her autonomy and dignity, and prevent her from missing a meal.
Choice A is wrong because omitting her breakfast will deprive her of nutrition and hydration, and may cause health problems.
It will also violate her rights as a resident.
Choice C is wrong because getting her up early enough to be ready for breakfast will disrupt her sleep cycle and may cause fatigue or stress.
It will also impose the nurse’s values on the resident, and disregard her preferences.
Choice D is wrong because having her go to breakfast regardless of the state of her grooming will embarrass her and lower her self-esteem.
It will also disrespect her culture and values, and may affect her social interactions.
Correct Answer is D
Explanation
Use a fresh washcloth when cleaning each eye. This is because using the same washcloth for both eyes can transfer microorganisms from one eye to the other and cause cross-infection.
The other choices are wrong because:
Choice A is wrong because wiping from the outer part of the eye toward the inner portion can introduce microorganisms into the tear ducts and cause infection.
Choice B is wrong because rinsing the washcloth before washing the second eye does not eliminate all the microorganisms that might be on the cloth.
Choice C is wrong because asking the client to roll the eyes upward does not prevent spreading organisms from one eye to the other when bathing a client.
Normal ranges for eye hygiene are to use a clean washcloth or cotton ball for each eye, wipe from the inner to the outer canthus, and use warm water or saline solution.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.