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A nurse is caring for a client.

Vital Signs Nurses Notes 1000:

T38.2° C (100.8°F), oral.

BP 114/56 mm Hg, supine HR 99/min

R 32/min

Pulse oximetry 85% on room air (95% to 100%)

1100:

T38.6° C (101.5°F), oral.

BP 112/54 mm Hg, supine Apical HR 108/min

Pulse oximetry 90% on 40% O2 via face mask

Pink mucous membrane is a normal finding.

R 22/min

Click to highlight the findings at 1100, that require follow-up. To deselect a finding, click on the finding again.

A.

T38.6° C (101.5°F), oral.

B.

BP 112/54 mm Hg, supine

C.

Apical HR 108/min

D.

R 22/min

E.

Pulse oximetry 90% on 40% O2 via face mask

F.

Pink mucous membrane is a normal finding.

Answer and Explanation

The Correct Answer is ["A","C","E"]

A.    Elevated oral temperature may indicate a fever and requires further assessment.
B.    This blood pressure value is within the normal range.
C.    An elevated heart rate (108/min) suggests tachycardia, and it requires further investigation to determine the cause.
D.    A respiratory rate of 22/min is not a finding that raises concern. 
E.    A pulse oximetry reading of 90% on supplemental oxygen (40% O2) is below the expected range, indicating potential respiratory distress and requiring immediate attention.
F.    Pink mucous membrane is a normal finding.


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Related Questions

Correct Answer is C

Explanation

A. Bilateral flank pain is more indicative of a possible renal issue, not an allergic transfusion reaction.
B. Elevated blood pressure is not a typical sign of an allergic transfusion reaction.
C. Generalized urticaria (hives) is a classic manifestation of an allergic transfusion reaction.
D. Distended jugular veins are not typically associated with an allergic transfusion reaction.

Correct Answer is B

Explanation

A. Peripheral edema is more associated with hypervolemia, not hypovolemia.
B. Oliguria (decreased urine output) is a common finding in hypovolemia due to decreased blood volume and reduced renal perfusion.
C. Hypertension is not typically associated with hypovolemia; hypotension is more common.
D. Bradycardia is not a typical finding in hypovolemia; tachycardia is more likely as a compensatory response to maintain cardiac output.

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