A nurse is caring for a 60-year-old male client in a provider’s clinic.

Exhibits

Click to select all the findings that require immediate follow-up.

Temperature 37.9°C (100.2°F)

Heart rate 97/min

Respiratory rate 24/min

Blood pressure 135/73 mmHg

Oxygen saturation 88% on room air

Pain 6 on a 0 to 10 scale

Answer and Explanation

Correct Answer : A,C,E

Choice A rationale: This temperature indicates a low-grade fever. Although not immediately life-threatening, it may suggest an underlying infection or inflammation that requires attention, especially given the client's other symptoms and elevated WBC count.

Choice B rationale: A heart rate of 97/min is slightly elevated but within the upper range of normal limits (60–100 bpm). This finding alone does not necessarily require immediate follow-up, especially without more severe symptoms.

Choice C rationale: A respiratory rate of 24/min is above the normal range (12–20 breaths/min) and may indicate respiratory distress or an underlying condition. The elevated rate, combined with low oxygen saturation, requires prompt follow-up.

Choice D rationale: The blood pressure reading of 135/73 mmHg is considered prehypertensive (normal range: <120/80 mmHg). While monitoring is essential, it does not immediately require follow-up in the context of other, more urgent issues.

Choice E rationale: An oxygen saturation of 88% on room air is significantly below the normal range (95–100%) and indicates hypoxemia. This requires immediate attention to address potential respiratory failure or other underlying causes.

Choice F rationale: Pain rated at 6 on a 0 to 10 scale is concerning but requires contextual evaluation. While high pain levels warrant attention, they are not immediately life-threatening compared to hypoxemia and respiratory distress.

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Correct Answer is ["B","D"]

Explanation

Choice A rationale

"QD" is an abbreviation for "once daily" but is not recommended due to potential misinterpretation as "QID" (four times daily), increasing the risk of medication errors.

Choice B rationale

"PO" is an accepted abbreviation for "by mouth" and is widely understood in medical practice, minimizing the risk of misinterpretation and ensuring clear communication of the administration route.

Choice C rationale

"APAP" is an abbreviation for acetaminophen but is not widely recognized and can lead to confusion, especially among patients and healthcare providers unfamiliar with the term.

Choice D rationale

"qhs" is an accepted abbreviation for "at bedtime" and is commonly used in medical practice, ensuring clear communication of the medication's timing without risk of significant misinterpretation. .

Correct Answer is ["100"]

Explanation

To determine the infusion rate.

Step 1 is (100 mL ÷ 60 min) × 60 min/hr.

Step 2 is (100 mL ÷ 60 min) = 1.67 mL/min.

Step 3 is 1.67 mL/min × 60 min/hr = 100 mL/hr.

Step 4 is to round the answer to the nearest whole number, which is 100.

Answer: 100 mL/hr.

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A nurse is caring for a 60-year-old male client in a provider’s clinic. Exhibits Click to select all the findings that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is transcribing a telephone prescription for acetaminophen 650 mg by mouth daily at bedtime.The nurse should identify that which of the following abbreviations are acceptable to use when transcribing the prescription?

Correct Answer is ["B","D"]

Explanation

Correct Answer is ["100"]

Explanation

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A nurse is caring for a 60-year-old male client in a provider’s clinic.

Exhibits

Click to select all the findings that require immediate follow-up.