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 B
Explanation
Background noise can interfere with the ability of a person with hearing loss to understand speech, even when wearing a hearing aid.
By turning off the television, the nurse can reduce background noise and improve communication with the client.
Choice A) Chewing gum is not an appropriate intervention to improve communication with a client who has hearing loss.
Choice C) Speaking loudly and clearly may help, but it is not as effective as reducing background noise.
Choice D) Using paper and pencil may be helpful in some situations, but it is not the most effective intervention to improve communication with a client who is wearing a hearing aid.
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].
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