A nurse is caring for a client.

Vital Signs

0800:

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 Nurses' Notes

0800:

Antibiotic administered as prescribed.

Bilateral breath sounds clear and present throughout. 0830

Client reports itching over the chest area and has urticaria over chest and trunk.

Client states tongue feels swollen

Bilateral breath sounds with scattered wheezing upon auscultation, Select the 4 findings that require immediate follow-up.

Heart rate

Blood pressure

Temperature

Urticaria

Swollen tongue

Breath sounds

Answer and Explanation

Correct Answer : B,D,E,F

A.   While elevated (104/min), it's essential, but not as critical as other findings.
B.   The significant drop in blood pressure from 108/56 mm Hg to 88/56 mm Hg within 30 minutes is a cause for immediate concern.
C.   The slight increase in temperature (from 37.6°C to 37.5°C) is important but not the most pressing concern.
D.   Itching over the chest with urticaria (hives) suggests an allergic reaction, requiring urgent attention.
E.   Swelling of the tongue is a severe sign of an allergic reaction and requires immediate intervention.
F.   Clear and present breath sounds with scattered wheezing indicate potential airway compromise, requiring immediate follow-up.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Stating that hospice care is the best option might not align with the client's wishes for continued treatment.
B. Encouraging the client to enjoy their time is supportive but doesn't address the client's request for more treatment.
C. Initiating a discussion with the healthcare provider allows the client to explore available treatment options while honoring their wishes.
D. Using phrases that emphasize the limited time left might not be supportive or respectful of the client's wishes for more treatment.

A. "I will weigh myself once weekly." B. "I will take my new medication in the evening." C. "I will leave a light on in my bathroom at night." D. "I will take a hot bath before going to bed."

Correct Answer is C

Explanation

A. Weighing once weekly might not be frequent enough for monitoring changes related to heart failure or medication effects.
B. The timing of hydrochlorothiazide administration isn't critical to safety considerations; it's typically taken in the morning due to its diuretic effect.
C. Leaving a light on in the bathroom at night can help prevent falls, a common concern in older adults, especially those with heart failure.
D. Taking a hot bath before bed might not contribute significantly to safety considerations related to heart failure or medication use.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a terminal illness. The client states, "I am not giving up. I want as much treatment as possible." Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is providing discharge teaching about safety considerations to an older adult client who lives at home. The client has heart failure and a new prescription for hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is prioritizing care for a client. Which of the following procedures should the nurse perform first?

A nurse is teaching a client how to self-administer heparin. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who requires airborne precautions. The nurse is preparing to leave the client's room following a dressing change. Which of the following pieces of personal protective equipment should the nurse remove first?

A nurse is preparing to administer packed RBCs to a client who has a low hemoglobin level. Which of the following actions should the nurse take prior to the start of the infusion?

A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, "I want to die now that my partner is gone." Which of the following responses should the nurse make?

A nurse is collecting a blood pressure (BP) reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mm Hg. Which of the following actions should the nurse take?

A nurse is conducting the Weber's test on a client. Which of the following is an appropriate action for the nurse to take?