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 B
Explanation
A. Respiratory rate is part of vital signs assessment but is not typically included in anthropometric measurements.
B. Weight is a key component of anthropometric assessment, measuring body mass or body weight.
C. Level of orientation pertains to the client's mental status and cognitive functioning, not part of anthropometric measurements.
D. Current pain level is important but not directly related to anthropometric measurements.
Correct Answer is D
Explanation
A. Dismissing the client's concerns by stating everything will be fine doesn’t acknowledge their anxiety or offer reassurance.
B. While validating common feelings of fear might be helpful, it doesn't directly address the client's concerns or provide coping strategies.
C. Asking why the client feels scared might come across as confrontational or probing, possibly escalating their anxiety.
D. Offering to discuss what the client can expect during their stay provides reassurance, helps manage expectations, and gives the client a sense of control and understanding about their situation.
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