A nurse is caring for a client.
Exhibit 1 Vital Signs 0800: Exhibit 2 Temperature 37.6° C (99.7° F) Blood pressure 108/56 mm Hg Heart rate 66/min Respiratory rate 18/min Pulse oximetry 97% on room air 0830: Temperature 37.5° C (99.5° F) Blood pressure 88/56 mm Hg Heart rate 104/min Respiratory rate 24/min Pulse oximetry 93% on room air Select the 4 findings that require immediate follow-up.
Temperature
Blood pressure
Respiratory rate
Pulse oximetry.
Heart rate.
Level of consciousness
Skin color and temperature
Correct Answer : B,D,E
The blood pressure has dropped significantly from 108/56 mm Hg to 88/56 mm Hg.
The pulse oximetry has decreased from 97% to 93%, indicating a decrease in oxygen saturation.
The heart rate has increased from 66/min to 104/min.
The level of consciousness is always an important factor to monitor in a patient.
A. Temperature: The temperature has only changed slightly and is within the normal range.
C. Respiratory rate: The respiratory rate has increased but is still within normal range.
G. Skin color and temperature: This information is not provided in the exhibit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When preparing medication from a vial for subcutaneous injection for a client, the nurse should hold the vial with the top facing upward while injecting air into the vial.
This is because injecting air into the vial equalizes the pressure inside and makes it easier to withdraw the medication 1.
Choice A is wrong because holding the syringe so that bubbles collect at the level of the plunger is not necessary when preparing medication from a vial.
Choice C is wrong because injecting air into the vial with the eye of the needle immersed in the fluid can contaminate the medication.
Choice D is wrong because holding the syringe at a 45° angle is not necessary when verifying dosage.
Correct Answer is D
Explanation
“I can apply lotion to soften calluses as long as I don’t put lotion between my toes.” This is because moisturizing can help keep skin soft and prevent corns and calluses from forming.
However, it is important to avoid putting lotion between the toes as this can increase the risk of infection 1.
Choice A is wrong because soaking feet in warm water daily can soften corns and calluses, making it easier to remove the thickened skin 2.
Choice B is wrong because while using corn pads can help protect the area where corn has formed, it is important to follow the manufacturer’s instructions for use and removal.
Choice C is wrong because using over-the-counter liquid medication to remove corn is not recommended for people with diabetes.
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