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
A. Determining what the client already knows about managing diabetes is the initial step in assessing the client's current knowledge and understanding. This helps the nurse tailor the teaching plan to the client's needs and avoid redundancy.
B. Providing access to a video about diabetes may be part of the teaching plan but should come after assessing the client's baseline knowledge.
C. Establishing short-term, realistic goals is important but should follow the assessment of the client's current knowledge and understanding.
D. Evaluating the effectiveness of the client's admission teaching plan is important but should occur after the initial assessment and implementation of a personalized teaching plan.
Correct Answer is B
Explanation
A. Skin color is not the most critical parameter before a blood transfusion.
B. Temperature is important to monitor for baseline and the temperature should be monitored during infusion since an increase in temperature can indicate a transfusion reaction.
C. Fluid intake is relevant to assess overall hydration status but not the most critical before the transfusion.
D. Hemoglobin level is crucial to determine but it is not the most important data to obtain immediately before the infusion, as it does not change rapidly during the transfusion and does not indicate an ongoing reaction.
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