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A nurse is caring for a client who has COPD.
The following are the client’s vital signs: Temperature 38.6C (101.5° F), BP 114/86 mm Hg, Heart rate 99/min, Respiratory rate 32/min, Oxygen saturation 85% on room air.
Which three findings require follow-up?

Blood pressure

Oxygen saturation

Temperature

Heart rate .

Answer and Explanation

Correct Answer : B,C,D

Choice A rationale

The blood pressure of 114/86 mm Hg is within the normal range and does not require follow- up.

Choice B rationale

The oxygen saturation of 85% on room air is below the normal range of 95% to 100%, indicating the client may be experiencing hypoxemia, which requires follow-up.

Choice C rationale

The temperature of 38.6C (101.5° F) is slightly elevated, indicating the client may have a fever, which requires follow-up.

Choice D rationale

The heart rate of 99/min is slightly elevated, indicating the client may be experiencing tachycardia, which requires follow-up.

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Correct Answer is A

Explanation

Choice A rationale

Auscultating lung sounds is the priority when monitoring for adverse effects of administering IV fluids. Fluid overload can lead to pulmonary edema, which would be detected by abnormal lung sounds such as crackles.

Choice B rationale

While measuring urine output is important to assess kidney function and fluid balance, it is not the priority in this case.

Choice C rationale

Monitoring blood pressure readings is important when administering IV fluids, but it is not the priority in this case.

Choice D rationale

Monitoring electrolyte levels is important when administering IV fluids, but it is not the priority in this case.

A. The top of the cane is parallel to the patient’s waist. B. The patient advances the cane 46 cm (18 in) forward while walking. C. The patient holds the cane on the side of their body that is stronger. D. The patient moves their stronger leg forward along with the cane.

Correct Answer is C

Explanation

Choice A rationale

While the top of the cane should be parallel to the client’s greater trochanter, this alone does not indicate correct use of the cane.

Choice B rationale

Advancing the cane 46 cm (18 in) forward while walking is too far. To maintain balance, the client should advance the cane about 15-30 cm (6-12 in) at a time.

Choice C rationale

The client should hold the cane on the stronger side of their body to increase support and maintain alignment. This is an indication of correct use.

Choice D rationale

The client should move their weaker leg forward with the cane. This divides the client’s body weight between the cane and the stronger leg.

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A nurse is caring for a client who has COPD.The following are the client’s vital signs: Temperature 38.6C (101.5° F), BP 114/86 mm Hg, Heart rate 99/min, Respiratory rate 32/min, Oxygen saturation 85% on room air.Which three findings require follow-up?

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Naxlex Comprehensive Predictor Exams

A nurse is administering fluids to a client.Which of the following assessments should the nurse identify as the priority when monitoring for adverse effects?

Correct Answer is A

Explanation

A nurse is assessing a patient’s ability to use a walking cane.Which of the following observations would indicate that the patient is using the cane correctly?

Correct Answer is C

Explanation

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A nurse is caring for a client who has COPD.
The following are the client’s vital signs: Temperature 38.6C (101.5° F), BP 114/86 mm Hg, Heart rate 99/min, Respiratory rate 32/min, Oxygen saturation 85% on room air.
Which three findings require follow-up?