Which set of vital signs, taken on an adult, is cause for concern and requires further evaluation?
Temperature 96.9°F; pulse 100 bpm; respirations 20 breaths/minute; blood pressure 120/80 mmHg.
Temperature 97.0°F; pulse 54 bpm; respirations 14 breaths/minute; blood pressure 196/114 mmHg.
Temperature 98.6°F; pulse 60 bpm; respirations 14 breaths/minute; blood pressure 110/66 mmHg.
Temperature 99°F; pulse 72 bpm; respirations 16 breaths/minute; blood pressure 100/60 mmHg.
The Correct Answer is B
Temperature 97.0°F; pulse 54 bpm; respirations 14 breaths/minute; blood pressure 196/114 mmHg.
This set of vital signs is cause for concern because the blood pressure is significantly elevated.
A blood pressure reading of 196/114 mmHg is considered a hypertensive crisis and requires immediate medical attention.
Choice A) Temperature 96.9°F; pulse 100 bpm; respirations 20 breaths/minute; blood pressure 120/80 mmHg is within normal limits for an adult.
Choice C) Temperature 98.6°F; pulse 60 bpm; respirations 14 breaths/minute; blood pressure 110/66 mmHg is also within normal limits for an adult.
Choice D) Temperature 99°F; pulse 72 bpm; respirations 16 breaths/minute; blood pressure 100/60 mmHg is slightly elevated but not cause for immediate concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The priority nursing intervention when a client begins to fall while ambulating is to guide the client safely to the floor.
This can help prevent injury and ensure the safety of the client.
CHOICE A. Initiating a code is not necessary for this situation as it is not a medical emergency.
CHOICE B AND D : Calling the charge nurse or the client’s doctor may be appropriate after the client has been safely guided to the floor and their condition has been assessed
[B] [D].
Correct Answer is A
Explanation
Pressure injuries may be a result of decreased mobility.
When a person has decreased mobility, they may spend extended periods of time in one position, which can put pressure on certain areas of the body and lead to the development of pressure injuries.
Choice B is not an answer because diarrhea is not typically a result of decreased mobility.
Choice C is not an answer because euphoria is not typically a result of decreased mobility.
Choice D is not an answer because increased energy is not typically a result of decreased mobility.
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