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 C
Explanation
Choice A rationale
A temperature of 36.5°C is considered normal.
Choice B rationale
A temperature of 37.5°C is slightly elevated but still within the normal range.
Choice C rationale
A temperature of 38.5°C is considered a fever. Given the client’s symptoms of a productive cough with thick yellow sputum and abnormal breath sounds, this could indicate an infection such as pneumonia, which would likely cause a fever.
Choice D rationale
A temperature of 39.5°C is a high fever and could indicate a severe infection. However, the client’s symptoms are more consistent with a moderate fever.
Correct Answer is C
Explanation
Choice A rationale
Hypertension refers to high blood pressure, which is not directly indicated by the given vital signs.
Choice B rationale
Hypotension, or low blood pressure, is also not directly indicated by the provided vital signs.
Choice C rationale
Tachycardia refers to a fast heart rate. If the patient’s heart rate increased significantly between 0800 and 0815, this could be a sign of tachycardia.
Choice D rationale
Bradycardia, or a slow heart rate, would be indicated by a decrease in heart rate, which is not suggested by the given information.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.