A nurse is caring for a client.
Exhibits
Select the 4 findings that require immediate follow-up.

Temperature

Breath sounds

Blood pressure

Heart rate

Swollen tongue

Urticaria

Answer and Explanation

Correct Answer : B,C,D,E

A.   The presence of wheezing indicates potential airway compromise, which is a significant concern in the context of an allergic reaction. Wheezing suggests bronchoconstriction and difficulty breathing, requiring immediate assessment and intervention to ensure adequate oxygenation.
B.   significant drop in blood pressure (hypotension) is a red flag for anaphylaxis, a severe and potentially life-threatening allergic reaction. Hypotension can lead to inadequate tissue perfusion and organ dysfunction, requiring immediate intervention with fluids and medications to stabilize blood pressure.
C.   rapid heart rate (tachycardia) can be a sign of an allergic reaction, particularly if accompanied by other symptoms such as hypotension or respiratory distress. Tachycardia may indicate the body's response to hypotension or increased sympathetic activity, and it warrants immediate follow-up to assess for shock or other complications.
D.   Swelling of the tongue (angioedema) can compromise the airway and lead to respiratory distress or obstruction. It is a concerning sign that requires immediate intervention to ensure the client's airway remains patent and adequate ventilation is maintained.
E.   A While an elevated temperature can indicate an inflammatory response, it is not typically the most concerning finding in an allergic reaction. In this case, the temperature elevation is mild and may be secondary to the allergic reaction, but it is not a critical priority for immediate follow-up compared to other findings.
F .Urticaria (hives) is a common manifestation of an allergic reaction and can be uncomfortable for the client. While it is important to address, it is typically not as immediately life-threatening as other symptoms such as wheezing or angioedema.

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

Explanation

B. Using grab bars when getting in and out of the bathtub helps prevent slips and falls, especially in wet or slippery conditions. This is an important safety measure, particularly for individuals with mobility issues or who are at risk of falling.
C. Having a fire escape plan with the family is crucial for preparedness in the event of a fire emergency. This includes identifying escape routes, practicing fire drills, and designating a meeting place outside the home. Having a plan can help ensure everyone's safety in case of a fire.
D. Checking medications for expiration dates is essential to ensure their effectiveness and safety. Expired medications may be less potent or could have potentially harmful effects. Discarding expired medications and obtaining new prescriptions as needed helps prevent medication errors and adverse reactions.
A. Applying tape over frayed areas of electrical cords is not a safe practice and can pose a fire hazard. Frayed cords should be replaced immediately to prevent electrical shocks or fires. Therefore, this statement does not indicate an understanding of home safety.
E. Setting the hot water heater to 140 degrees Fahrenheit (Choice E) is not recommended as it can pose a scalding risk, especially for young children and older adults with sensitive skin. The recommended

temperature for hot water heaters is typically around 120 degrees Fahrenheit to reduce the risk of scalds while still providing hot water for daily use. Therefore, this statement does not indicate an understanding of home safety.

A. Respiratory rate B. Weight C. Level of orientation D. Current pain level

Correct Answer is B

Explanation

Rationale
B. Weight is a key component of the anthropometric assessment as it provides important information about the client's nutritional status, growth patterns, and overall health. Changes in weight can indicate changes in body composition, hydration status, or underlying health conditions.
A. Respiratory rate is not part of the anthropometric assessment
C. level of orientation is not part of the anthropometric assessment
D. current pain level is not part of the anthropometric assessment.

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A nurse is caring for a client. Exhibits Select the 4 findings that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

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Correct Answer is B

Explanation

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A nurse is caring for a client.
Exhibits
Select the 4 findings that require immediate follow-up.