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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Free Nursing Study Resources

Correct Answer is B

Explanation

B. When the client believes that learning how to self-administer daily low-dose heparin injections will meet their needs, such as improving their health, managing their condition effectively, or promoting independence, they are more likely to be motivated to engage in the learning process.
A. Understanding the importance of education is crucial, but it may not directly impact the client's motivation unless it is coupled with other factors.
C. While seeking family approval may be a motivating factor for some clients, it may not necessarily be the most significant factor in increasing motivation to learn.
D. Empathy from the nurse can create a positive learning environment and foster trust between the nurse and client, which can indirectly contribute to the client's motivation. However, the client's motivation is primarily influenced by their own beliefs, needs, and perceived benefits of education.

A. Prepare the client for surgery. B. Obtain consent from the surgeon. C. Contact the facility's ethics committee for guidance D. Keep the client stable until a family member arrives to give consent.

Correct Answer is A

Explanation

A. In an emergency situation where a patient is unconscious and unable to give consent, and there is no available family member or designated surrogate to provide consent, healthcare providers can proceed with life-saving treatment under the principle of implied consent. This principle assumes that a reasonable person would consent to treatment if they were able to do so.

B.The surgeon cannot give consent for the patient. Consent must come from the patient or a legally authorized representative.
C. In situations where consent cannot be obtained from the patient or a legally authorized representative, involving the ethics committee can be a prudent course of action. However, this may delay emergency care.
D. This option may be appropriate if there is a reasonable expectation that a family member or legally authorized representative will arrive within a reasonable timeframe. However, in emergency situations where immediate intervention is necessary to save the patient's life or prevent serious harm, waiting for consent may not be feasible.

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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

A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?

Correct Answer is B

Explanation

A nurse in an emergency department is caring for a client who is unconscious and requires surgery. There is no one available to give consent for the treatment. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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