A nurse is assisting with the care of a client

Exhibits

Select the 3 findings that require immediate follow-up.

Breath sounds at 1600

Temperature

Urticaria

Blood pressure at 1630

Report of dysphagia

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. While itching and hives can be signs of a mild allergic reaction, difficulty breathing and low blood pressure indicate a more severe issue. Treating a severe reaction as mild can delay necessary emergency interventions, potentially leading to life-threatening consequences.
B. The symptoms described, including difficulty breathing and hypotension, suggest a severe, not moderate, allergic reaction. This misjudgment can result in insufficient treatment and delay life-saving measures.
C. Anaphylactic reactions are characterized by symptoms such as hives, difficulty breathing, and low blood pressure, requiring immediate emergency treatment. Prompt recognition and intervention are critical to prevent severe complications or death.
D. Food poisoning typically presents with gastrointestinal symptoms rather than respiratory distress and hypotension. Misdiagnosing an anaphylactic reaction as food poisoning can prevent timely administration of appropriate treatments like epinephrine.

A. 1 pint is equal to 960 mL B. 1 tsp is equal to 10 mL C. 2 Tbsp is equal to 15 mL D. 1 cup is equal to 240 Ml

Correct Answer is D

Explanation

A. 1 pint is actually approximately 473 mL, not 960 mL, making this conversion incorrect. Providing accurate conversion information is essential for ensuring proper medication dosing and patient safety.
B. 1 teaspoon (tsp) is equal to 5 mL, not 10 mL. Incorrect conversions can lead to dosing errors, potentially resulting in underdosing or overdosing.
C. 2 tablespoons (Tbsp) is actually equal to 30 mL, not 15 mL. Accurate conversions are crucial for patient safety, particularly in pediatric and elderly populations where precise dosing is critical.
D. 1 cup is correctly equal to 240 mL, making this conversion accurate. Correct conversions ensure that patients receive the appropriate volume of medication or fluid.

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A nurse is assisting with the care of a client Exhibits Select the 3 findings that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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A nurse is assisting with the care of a client

Exhibits

Select the 3 findings that require immediate follow-up.