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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Assessing skin temperature and color is crucial to ensure circulation and skin integrity before applying restraints.
B. Attaching restraints to the bed rail isn't considered best practice, as it can lead to entrapment and injury.
C. Ensuring the client's bed is in the lowest position is essential to prevent falls and reduce the risk of injury if the client attempts to leave the bed.
D. Padding bony prominences helps prevent skin breakdown and discomfort.
E. Securing restraints to allow two fingers and not three,to slide under them ensures proper fit and prevents excessive tightness that could impair circulation.
Correct Answer is D
Explanation
A. Sterile gloves, not clean gloves, should be worn when cleaning the inner cannula to reduce the risk of introducing infection into the tracheostomy site, which is a direct pathway to the airway.
B. Placing gauze pads under the flanges of the tracheostomy tube isn't a standard practice for tracheostomy care.
C. Cleansing the skin around the stoma with full-strength hydrogen peroxide can be too harsh and irritating to the skin.
D. Using a tracheostomy collar with hook-and-loop fasteners is a safe and effective way to secure the tracheostomy tube, ensuring it remains in place while minimizing the risk of skin breakdown and irritation. This method also allows for easier adjustment and replacement of the collar.
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