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 A
Explanation
Rationale:
A. Negligence involves failing to provide care that a reasonably prudent nurse would provide, such as leaving a shift early without proper handoff or notification, which could compromise patient safety.
B. Battery involves unlawful touching of a patient without consent, which is not applicable in this situation.
C. Slander involves making false spoken statements that harm a person's reputation, which is not applicable in this situation.
D. Libel involves making false written statements that harm a person's reputation, which is not applicable in this situation.
Correct Answer is B
Explanation
A. Hypoglycemia is not a risk factor for metabolic syndrome; hyperglycemia is more relevant.
B. A large waist size (abdominal obesity) is a significant risk factor for metabolic syndrome, which includes a cluster of conditions such as increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol levels.
C. History of asthma is not directly related to metabolic syndrome.
D. Hypotension is not a risk factor for metabolic syndrome; hypertension is more relevant.
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