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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Rationale:

A. Removing the nasal cannula while the client eats can interrupt oxygen therapy.

B. Attaching a humidifier bottle to the base of the flow meter helps to humidify the oxygen, preventing dryness and irritation of the nasal passages, which is appropriate for oxygen flow rates above 4 L/min.

C. Applying petroleum jelly to the nares can pose a fire hazard due to its petroleum base.

D. Securing the oxygen tubing to the bed sheet is not necessary and does not ensure the proper administration of oxygen.

A. Elevated WBC B. Fever C. Fatigue D. Ecchymosis

Correct Answer is D

Explanation

A. Elevated WBC is not typically associated with ITP, which primarily affects platelet counts.
B. Fever may indicate infection but is not specific to ITP.
C. Fatigue can occur in clients with ITP due to anemia or chronic illness but is not specific to the condition.
D. Ecchymosis (bruising) is a hallmark manifestation of ITP due to low platelet counts and increased bleeding tendencies.

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36. A nurse is caring for a client. Exhibits Which of the following findings at 1015 requires further action?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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36. A nurse is caring for a client.
Exhibits
Which of the following findings at 1015 requires further action?