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 B

Explanation

A. The therapeutic effect of Benadryl is to relieve allergy symptoms, not cause drowsiness.
B. Drowsiness is a common side effect of Benadryl, as it is an antihistamine that can cause sedation.
C. Toxic effects refer to harmful effects due to excessive dosing, not typical side effects at therapeutic doses.
D. An allergic reaction would involve symptoms such as rash, itching, or swelling, not drowsiness.

A. The client reports having trouble sleeping the previous night. B. The client reports dizziness when ambulating to the bathroom. C. The client has a urine output of 400 mL for the past 8 hr D. The client ate 60% of their breakfast.

Correct Answer is B

Explanation

A. Trouble sleeping the previous night may not be directly related to the decision to withhold antihypertensive medication.
B. Dizziness when ambulating could indicate hypotension, which can be exacerbated by antihypertensive medication. The nurse should collect further data to ensure the patient's blood pressure is safe for medication administration.
C. Urine output is important to monitor but does not directly indicate a need to withhold antihypertensive medication unless associated with other symptoms.
D. Eating 60% of breakfast does not indicate a need to collect further data before administering antihypertensive medication.

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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

A woman has been prescribed a daily Benadryl for allergy symptoms by her health care provider. She recently began have difficulty staying awake at work, most likely this is related to the Benadryl. Which of the following best describes this response?

Correct Answer is B

Explanation

A nurse is preparing to administer a client's antihypertensive medication. When using clinical judgment, which of the following findings indicates the nurse should collect further data from the client before administering medication?

Correct Answer is B

Explanation

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A nurse is assisting with the care of a client

Exhibits

Select the 3 findings that require immediate follow-up.