A nurse is caring for a client.
Vital Signs.
1600: Nurses' Notes.
Temperature 37.6°C (99.7°F). Blood pressure 110/58 mm Hg. Heart rate 72/min.
Respiratory rate 18/min.
Pulse oximetry 98% on room air.
1630: Temperature 37.5°C (99.5°F). Blood pressure 78/52 mm Hg. Heart rate 112/min.
Respiratory rate 26/min.
Pulse oximetry 92% on room air.
1600: Antibiotic administered as prescribed.
Bilateral breath sounds clear and present throughout.
1630: Client reports itching on the chest and has urticaria over the chest and trunk.
Client states they are having difficulty swallowing and feel as if there is a lump in their throat.
Bilateral breath sounds with scattered wheezing heard throughout.
Vital Signs.
Nurses' Notes.
Medication Administration Record.
Cefaclor 500 mg PO q8h.
Select the 3 findings that require immediate follow-up.
Breath sounds at 1600.
Temperature.
Urticaria.
Blood pressure at 1630.
Report of dysphagia.
Correct Answer : C,D,E
The correct answer is to select the following three findings that require immediate follow-up: C. Urticaria, D. Blood pressure at 1630, and E. Report of dysphagia.
Choice A rationale:
“Breath sounds at 1600.” The breath sounds at 1600 were clear and present throughout, which is a normal finding and does not require immediate follow-up.
Choice B rationale:
“Temperature.” The temperature readings at both 1600 and 1630 are slightly elevated but not critically high. This does not require immediate follow-up compared to the other findings.
Choice C rationale:
“Urticaria.” The presence of urticaria (hives) indicates an allergic reaction, which can potentially escalate to a more severe reaction such as anaphylaxis. Immediate follow-up is necessary to prevent further complications.
Choice D rationale:
“Blood pressure at 1630.” The blood pressure at 1630 is significantly lower (78/52 mm Hg) compared to the earlier reading (110/58 mm Hg). This hypotension could indicate a serious reaction to the medication or another underlying issue that requires prompt attention.
Choice E rationale:
“Report of dysphagia.” The client’s report of difficulty swallowing and feeling a lump in their throat is concerning for a potential airway obstruction or severe allergic reaction, such as anaphylaxis. This symptom requires immediate follow-up to ensure the client’s airway remains open and to provide necessary interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
While the principle of justice is essential in healthcare, it does not directly address the client's decision to proceed with elective surgery or not. Justice pertains more to the fair allocation of resources and the equitable treatment of individuals, which may not directly apply to the client's autonomy in this situation.
Choice B rationale:
The principle of fidelity relates to keeping promises and being faithful to commitments, but it may not be the primary ethical principle to consider in this situation. The client's decision to proceed with elective surgery is primarily a matter of personal autonomy, and the nurse should prioritize respecting the client's autonomy over fidelity.
Choice C rationale:
Veracity is the principle of truthfulness and honesty in communication, but it does not take precedence over the client's autonomy in this context. While it is important for the nurse to provide honest information, the client's autonomous decision to proceed with or decline surgery should be respected regardless of the nurse's communication of truthful information. .
Correct Answer is A
Explanation
Choice A rationale:
Economic stability is one of the key factors of the social determinants of health (SDOH) that significantly impacts an individual's well-being. In this case, the client reporting unemployment indicates a lack of economic stability. Economic stability encompasses factors such as employment, income, and financial resources, and it can affect access to healthcare, nutrition, housing, and other social determinants of health. The client's unemployment is a challenge to their overall health.
Choice B rationale:
Neighborhood environment is another SDOH factor, which includes aspects like the quality of housing, safety, and access to parks and recreational areas. While neighborhood environment can impact health, the client's unemployment directly relates to economic stability and its challenges, making choice A the more appropriate answer.
Choice C rationale:
Education is a crucial SDOH factor, as it can influence employment opportunities, income, and health literacy. However, in this specific scenario, the client's primary concern is their unemployment. While education is a related factor, choice A (economic stability) is more directly applicable to the client's situation.
Choice D rationale:
Social and community context includes factors like social support, social norms, and community engagement. While this factor is important for overall health, the client's immediate challenge is economic stability due to unemployment. Social and community context may play a role in addressing unemployment, but it is not the factor that is currently challenging the client the most.
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