A nurse is caring for a 60-year-old male client in a provider’s clinic.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Terazosin is an alpha-1 adrenergic blocker used primarily to treat hypertension by relaxing blood vessels and improving blood flow.
Choice B rationale
Terazosin is not indicated for heart failure treatment as it does not have direct effects on improving cardiac function or reducing fluid overload.
Choice C rationale
Male pattern baldness is typically treated with medications like minoxidil or finasteride, not terazosin, which targets alpha-1 receptors.
Choice D rationale
Benign prostatic hypertrophy is also treated with terazosin as it relaxes the smooth muscle in the prostate and bladder neck, improving urine flow.
Choice E rationale
Erectile dysfunction is managed with medications like sildenafil or tadalafil, which work by enhancing blood flow, not through alpha-1 adrenergic blockade.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
Indicated Actions:
Clindamycin 600 mg IV every 8 hours: This is an appropriate antibiotic choice for someone with a penicillin allergy. Clostridium infections and Streptococcus species can be treated with clindamycin.
Albuterol 2.5 mg/3 mL aerosol: This medication is used to relieve dyspnea by bronchodilation, which is beneficial for a client with chronic obstructive pulmonary disease.
Acetaminophen 325 mg PO: This is used to manage fever. The client's temperature is elevated at 38.7°C (101.7°F), so this prescription is indicated.
Oxygen via nasal cannula at 8 L/min: The client's SpO₂ level has dropped to 87% on room air, indicating the need for supplemental oxygen to maintain adequate oxygen saturation.
0.9% sodium chloride (NaCl) at 200 mL/hr: Intravenous fluid administration is necessary to maintain hydration and improve blood pressure in a client with hypotension.
Not Indicated Action:
Piperacillin-tazobactam 4500 mg IV: This antibiotic is contraindicated due to the client's documented penicillin allergy. Piperacillin is a penicillin derivative, and administering it could trigger a severe allergic reaction.
Each of these actions has been considered carefully based on the client's medical history, current condition, and standard medical practices.
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