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 .
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The statement “What did I do to deserve this illness?” could indicate spiritual distress. This statement suggests that the patient may be struggling with feelings of guilt, punishment, or existential crisis, which are common manifestations of spiritual distress. The patient may be
questioning their moral or spiritual worth, or trying to find meaning or purpose in their suffering.
Choice B rationale
The statement “I blame medical science for not finding a cure” could indicate frustration or anger, but it does not necessarily indicate spiritual distress. While this statement suggests dissatisfaction with medical progress, it does not directly relate to the patient’s spiritual or existential concerns.
Choice C rationale
The statement “Where is my daughter when I need her most?” could indicate emotional distress related to the patient’s interpersonal relationships, but it does not necessarily indicate spiritual distress. This statement suggests that the patient may feel abandoned or unsupported, but it does not directly relate to the patient’s spiritual or existential concerns.
Choice D rationale
The statement “Will I ever regain control over my life?” could indicate emotional distress related to the patient’s sense of autonomy and control, but it does not necessarily indicate spiritual distress. This statement suggests that the patient may feel helpless or powerless in the face of their illness, but it does not directly relate to the patient’s spiritual or existential concerns.
Correct Answer is D
Explanation
Choice A rationale
Biofeedback is a mind-body technique that helps individuals gain control over bodily processes that are normally involuntary. It is not contraindicated for a client with herpes zoster.
Choice B rationale
Aloe is a plant-based product often used for its soothing and healing properties. It is not contraindicated for a client with herpes zoster.
Choice C rationale
Feverfew is a medicinal herb often used for its anti-inflammatory properties. It is not contraindicated for a client with herpes zoster.
Choice D rationale
Acupuncture involves the insertion of thin needles into specific points on the body. It is contraindicated for a client with herpes zoster because it could potentially open a portal on the skin’s surface, increasing the risk of further infection.
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