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
The mission of the Occupational Safety and Health Administration (OSHA) is to ensure safe and healthful working conditions for workers by setting and enforcing standards and by providing training, outreach, education, and assistance1.
This was established by Congress with the Occupational Safety and Health Act of 19701.

Choice A is incorrect because OSHA’s mission is focused on protecting workers, not clients.
Choice C is incorrect because OSHA’s focus is on preventing work-related injuries, illnesses, and deaths, not injuries a nurse may incur at home.
Choice D is incorrect because OSHA’s mission is not focused on reducing client falls or providing emotional support.
Correct Answer is C
Explanation
The nurse’s priority action when an eight-year-old child is eating a hotdog and begins coughing is to promote coughing.
Coughing is the body’s natural way of trying to clear an obstruction from the airway.

Choice A is not the correct answer because beginning the Heimlich maneuver quickly is not the first action that should be taken.
Choice B is not the correct answer because telling the child to put his hands by his neck to signify that he is choking is not the first action that should be taken.
Choice D is not the correct answer because leaving the child alone to find a phone is not the first action that should be taken.
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