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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Correct Answer is ["A","B","C"]

Explanation

A. Placing the client in high Fowler's position helps improve lung expansion and oxygenation.
B. Administering oxygen helps address hypoxia and supports adequate oxygenation.
C. Stopping the transfusion is crucial when signs of a transfusion reaction are present.
D. Administering a diuretic is not typically indicated for transfusion reactions involving lung crackles, hypoxia, and distended neck veins.
E. Epinephrine is not typically used to manage a blood transfusion reaction; it's more for severe allergic reactions like anaphylaxis.

A. "I will avoid exposure to the sun." B. "I will decrease my intake of dairy products." C. "I will walk three times per week." D. "I will take 250 milligrams of calcium once per day."

Correct Answer is C

Explanation

A. Avoiding exposure to the sun might decrease vitamin D synthesis, which is necessary for calcium absorption.

B. Decreasing intake of dairy products may decrease calcium intake, which could increase the risk of osteoporosis.
C. Regular weight-bearing exercises like walking help maintain bone density and reduce the risk of osteoporosis.
D. A daily calcium intake of 250 milligrams might be insufficient for osteoporosis prevention; the recommended daily intake varies based on age and gender.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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.)

Correct Answer is ["A","B","C"]

Explanation

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?

Correct Answer is C

Explanation

A nurse is preparing to perform an anthropometric assessment on a client. Which of the following client data should the nurse include?

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 preparing to reposition a client who has a lower back injury. Which of the following actions should the nurse take?

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 performing an eye assessment for a newly admitted client. Which of the following findings should the nurse expect?

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 home health nurse is assessing the home environment of an older adult client who has osteoporosis. For which of the following findings should the nurse intervene?

A nurse manager overhears a nurse telling a client, "I will administer your medication by injection if you don't swallow your pills." The nurse manager should identify that the nurse is committing which of the following torts?