36. A nurse is caring for a client.
Exhibits
Which of the following findings at 1015 requires further action?
(Select all that apply.)
Low back pain
Urine color
Blood pressure
Respiratory rate
Correct Answer : C,D
A. While low back pain can be concerning, it's not an immediate priority compared to the vital sign changes. However, the nurse should document the pain and ask about its characteristics.
B. Brown-colored urine can sometimes indicate dehydration or certain medical conditions, requiring follow-up.
C. A significant drop in blood pressure (74/50 mmHg) indicates hypotension and requires immediate attention.
D. An increase in respiratory rate (28 breaths/min) suggests the client may be experiencing respiratory distress and needs evaluation.
E. The client’s oxygen saturation is 95% on room air which is normal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E","F"]
Explanation
A. Pneumococcal vaccine → Not having it increases risk, but the option itself (“Pneumococcal vaccine”) is misleading; risk comes from lack of vaccine, not its presence.
B. Level of consciousness → Client is lethargic and has difficulty answering questions, which can increase risk of aspiration and reduce effective airway clearance.
C. Influenza vaccine → Similarly, not getting the vaccine is a risk, but the option is phrased as “Influenza vaccine,” which is protective, not a risk factor.
D. Health history → Lack of pneumococcal and influenza vaccinations increases susceptibility to respiratory infections.
E. Fluid intake → Client reports reduced fluid intake, leading to thickened secretions, impaired mucociliary clearance, and higher risk of pneumonia.
F. Age → Middle-aged and older adults are at higher risk for pneumonia due to decreased physiologic reserve.
G. Smoking history → Smoking history is incorrect. While a history of smoking, or exposure to second-hand smoke, increases a client’s risk of contracting community-acquired pneumonia, the client reports no smoking history.
Correct Answer is A
Explanation
A. Discussing initiating hospice care is appropriate to address the client's desire to go home for end-of-life care and to provide support and resources for the family.
B. Extending the hospital stay may not align with the client's wishes for end-of-life care at home.
C. Placing the client in a nursing home may not be in line with the client's preference to go home.
D. While the family may provide palliative care, the nurse should also explore hospice care options for comprehensive support.
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