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 A

Explanation

A. Metabolic syndrome is a cluster of conditions that include high blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels, all of which increase the risk of cardiovascular disease.
B. Participation in competitive sports might enhance cardiovascular fitness and decrease the risk of cardiovascular diseases.
C. While alcohol use disorder can have health implications, it's not a direct risk factor for cardiovascular disease.
D. Hypotension (low blood pressure) is generally not considered a significant risk factor for cardiovascular disease, unlike hypertension (high blood pressure).

A. Adjust the oxygen flow rate as needed to ease breathing. B. Antibiotic therapy should be taken for 10 days. C. Store the oxygen cylinder wrench with the oxygen tank. D. Ensure the oxygen delivery system is at least 8 feet from any heat source. E. Steroid medication should be taken in the morning. F. Antibiotic medication can be taken with or without food. G. The steroid dose will decrease each day.

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

Explanation

A. Adjusting the oxygen flow rate as needed is incorrect because oxygen is a prescribed medical gas. The client or caregiver must never alter the flow rate based on subjective breathing comfort; it should only be adjusted under the explicit direction of the healthcare provider.

B. Antibiotic therapy should be taken for 10 days is an incorrect assumption. The client’s cefazolin IV was discontinued on Day 4, and the provided chart details do not show an ongoing oral antibiotic prescription intended for home use.

C. Storing the oxygen cylinder wrench with the oxygen tank is a critical safety practice. This ensures that the specialized wrench needed to quickly turn the tank valve on or off is immediately accessible to the client or caregiver during an emergency or tank change.

D. Ensuring the oxygen delivery system is at least 8 feet from any heat source is an essential home fire-safety measure. Oxygen strongly accelerates combustion, so keeping tanks and tubing far away from sources like stoves, space heaters, or open flames prevents accidental fires.

E. Steroid medication should be taken in the morning because systemic corticosteroids can cause significant insomnia and central nervous system stimulation if taken later in the day. A morning dose also closely mimics the body's natural diurnal rhythm of cortisol release.

F. Antibiotic medication can be taken with or without food is incorrect because the client's current IV antibiotic therapy was discontinued, and there is no active prescription for a home oral antibiotic listed in the medical records to teach about.

G. The steroid dose will decrease each day is incorrect based on the medical records. The client is prescribed a steady dose of prednisone 40 mg daily, and there is no indication or instruction in the MAR for a daily tapering schedule at this time.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is obtaining a health history from a client. Which of the following factors places the client at risk for cardiovascular disease?

Correct Answer is A

Explanation

A nurse is caring for a client who has pneumonia Exhibits The nurse is providing discharge teaching for the client and their caregiver. Which of the following information should the nurse include? Select all that apply.

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

Explanation

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse plan to take?

A nurse in a provider's office is caring for a client. Exhibits The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for osteoporosis? (Select all that apply.)

A nurse is planning to change a client's tracheostomy ties. Which of the following actions should the nurse take?

A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

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?

A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

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 teaching an older adult client about reducing the risk for osteoporosis. Which of the following statements by the client indicates an understanding of the teaching?