A nurse is assisting with the care of a client
Select the 3 findings that require immediate follow-up.
Breath sounds at 1600
Temperature
Urticaria
Blood pressure at 1630
Report of dysphagia
Correct Answer : C,D,E
A. Bilateral breath sounds clear and present throughout at 1600 are normal findings and do not require immediate follow-up.
B. The temperature at both 1600 (37.6°C) and 1630 (37.5°C) is slightly elevated but not critically high. It does not require immediate follow-up unless it worsens significantly or is accompanied by other concerning symptoms.
C. Urticaria (hives) over the chest and trunk, along with itching and difficulty swallowing (dysphagia), are signs of an allergic reaction, which requires immediate follow-up and assessment.
D. The blood pressure decreased to 78/52 mm Hg at 1630 from 110/58 mm Hg at 1600. This significant drop indicates hypotension and requires immediate follow-up.
E. Difficulty swallowing (dysphagia) reported by the client suggests a potential airway compromise and requires immediate follow-up to assess the severity and intervene accordingly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Employee assistance programs (EAP) offer support services to employees but do not define the scope of nursing practice.
B. The US Food and Drug Administration (FDA) regulates food and drugs but does not define nursing practice.
C. The MedWatch program is a safety information and adverse event reporting system, not related to defining nursing scope.
D. State Nurse Practice Acts define the legal scope of nursing practice, including what tasks can be delegated to unlicensed personnel, ensuring safe and competent care.
Correct Answer is C
Explanation
A. To find the number of tablets to administer: 0.25 mg (prescribed dose) ÷ 0.125 mg/tablet (available dose) = 2 tablets.
B. To find the number of tablets to administer: 0.25 mg (prescribed dose) ÷ 0.125 mg/tablet (available dose) = 2 tablets.
C. To find the number of tablets to administer: 0.25 mg (prescribed dose) ÷ 0.125 mg/tablet (available dose) = 2 tablets.
D. To find the number of tablets to administer: 0.25 mg (prescribed dose) ÷ 0.125 mg/tablet (available dose) = 2 tablets.
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