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.

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.

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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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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.

A. “I will receive help with managing my meals with this service.” B. “I will need to go to a skilled facility to receive these services.” C. “This service provides my caregiver the opportunity to take time for themselves.” D. "This service assists with making me comfortable during my illness."

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is experiencing hypovolemia. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is providing teaching to a client who has a terminal illness and is considering palliative care services. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects metabolic acidosis. Which of the following results should the nurse expect to see?

A nurse is caring for a client. Exhibits For which of the following interprofessional team members should the nurse anticipate a provider's referral? Select all that apply.

A nurse is caring for a client who is unconscious and has a living will. The client's family asks if they can make changes to lifesaving measures now that the client is unconscious. Which of the following statements should the nurse make?

A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?

A nurse is caring for a client who is experiencing severe nausea and vomiting after a course of chemotherapy. The nurse should monitor the client for which of the following clinical manifestations?

A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is effectively responding to treatment?

A nurse is preparing to administer potassium chloride (KCL) to a client who is receiving diuretic therapy. The nurse reviews the client's serum potassium level results and discovers the client's potassium level is 3.2 mEq/L. Which of the following actions should the nurse take?

A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mm Hg a the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate of which of the following acid base balances?