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","D","E"]

Explanation

A. Urine-specific gravity greater than 1.030 is indicative of concentrated urine and is more associated with dehydration, not fluid volume excess.
B. Pitting edema is a classic sign of fluid volume excess, indicating an accumulation of fluid in the interstitial spaces.
C. Swelling at the IV site may be related to local inflammation or extravasation of fluids but is not specific to fluid volume excess.
D. Crackles upon auscultation suggest fluid accumulation in the lungs, which is a common finding in fluid volume excess.
E. A bounding pulse is often associated with increased stroke volume and can be a sign of fluid volume excess.

A. Inability to form healthy relationships B. Bedwetting C. Overeating D. Feelings

Correct Answer is C

Explanation

A. This is more related to psychological changes rather than physiological changes in older adults.
B. Bedwetting is not a typical physiological change in older adults. It is more commonly associated with children.
C. Older adult clients might experience changes in their appetite and metabolism that can lead to overeating and obesity. This can increase the risk of chronic diseases such as diabetes, hypertension, and cardiovascular problems.
D. While emotional changes may occur, the term "feelings" is too broad. Physiological changes are more specific to bodily functions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing an older adult client who is receiving IV therapy. The nurse should recognize that which of the following findings indicates fluid volume excess? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

A nurse is assisting with teaching a class about expected physiological changes in older adult clients. Which of the following changes should the nurse include?

Correct Answer is C

Explanation

A nurse is instructing a group of clients regarding calcium rich foods. Which of the following foods should the nurse include in the teaching as the best source of calcium?

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 preparing to administer 40 mEq of potassium chloride in 45% sodium chloride (NaCl) 500 mL IV to infuse 10 mEq/hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

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 receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?

A nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. Which of the following findings should the nurse recognize as a potential causative factor?

A nurse is assessing a client who is at the end of life. Which of the following findings should the nurse expect?

A nurse is caring for a group of clients. Which of the following clients is eligible for hospice care?