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
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T38.6° C (101.5°F), oral.
BP 112/54 mm Hg, supine
Apical HR 108/min
R 22/min
Pulse oximetry 90% on 40% O2 via face mask
Pink mucous membrane is a normal finding.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A: Palliative care includes holistic care, but it's not primarily focused on managing meals.
B: Palliative care can be provided at various locations, including the client's home, not necessarily a skilled facility.
C: While palliative care may support caregivers, its primary focus is on the comfort and well-being of the client.
D: Palliative care aims to make the client comfortable physically, emotionally, and spiritually during a terminal illness.
Correct Answer is A
Explanation
A. The low pH (below the normal range of 7.35-7.45) indicates acidosis. The elevated PaCO2 (above the normal range of 35-45 mm Hg) suggests respiratory involvement, indicating respiratory acidosis.
B. Metabolic acidosis is characterized by a low pH and low HCO3, not an elevated PaCO2.
C. Respiratory alkalosis is characterized by a high pH and low PaCO2.
D. Metabolic alkalosis is characterized by a high pH and high HCO3.
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