A nurse is assessing a client who has a fever, an infection of a flank incision, and is in severe pain. Which type of pulse rate would the client most likely exhibit?
Bradycardia.
Bigeminal.
Dysrhythmia.
Tachycardia.
The Correct Answer is D
The client would most likely exhibit tachycardia, which is an abnormally fast heart rate. Fever and infection can both cause an increase in heart rate as the body tries to fight off the infection. Severe pain can also cause an increase in heart rate due to the body's stress response. Therefore, it is likely that the client would have a fast pulse rate, or tachycardia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
An unlicensed assistive person (UAP) is a healthcare worker who is not licensed to perform nursing tasks but can assist with basic care under the supervision of a licensed nurse. Taking and recording vital signs is a task that can be delegated to a UAP. Making a bed and assisting with bathing are also tasks that can be delegated to a UAP. However, an unlicensed assistive person may not delegate tasks to others as they are not licensed to do so.
Correct Answer is D
Explanation
A stage II pressure ulcer is a wound that involves partial-thickness loss of skin. The most appropriate NANDA nursing diagnosis problem statement for a client with this condition would be Impaired Skin Integrity. This diagnosis reflects the fact that the client's skin has been damaged and is no longer intact. Risk for Injury, Altered Tissue Perfusion, and Impaired Tissue Integrity are also NANDA nursing diagnoses, but they are not as specific or relevant to the client's condition as Impaired Skin Integrity.

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