A nurse is obtaining a client's vital signs. Which of the following findings should the nurse report to the charge nurse?

Heart rate 98/min

Temperature 38.0 °C (100.4 °F)

Respiratory rate 14/min

Blood pressure 142/88 mm Hg

Answer and Explanation

The Correct Answer is B

A. Heart rate 98/min. A heart rate of 98 beats per minute is within the normal range for adults, which is typically between 60 and 100 beats per minute. Therefore, this finding does not require reporting.
B. Temperature 38.0 °C (100.4 °F). A temperature of 38.0 °C (100.4 °F) is considered a low-grade fever and may indicate an infection or other underlying condition. This finding should be reported to the charge nurse for further assessment and potential intervention.
C. Respiratory rate 14/min. A respiratory rate of 14 breaths per minute is within the normal range for adults, which is generally between 12 and 20 breaths per minute. This finding does not require reporting.
D. Blood pressure 142/88 mm Hg. A blood pressure reading of 142/88 mm Hg is classified as elevated or stage 1 hypertension. While it is important to monitor blood pressure, this finding may not require immediate reporting unless there are additional concerning symptoms or a significant change from the client's baseline readings.

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Correct Answer is B

Explanation

A. Confusion can occur with electrolyte imbalances, including hyperkalemia, but it is not the most common or specific symptom associated with elevated potassium levels. More typical symptoms are related to muscle and gastrointestinal function.
B. Abdominal cramps are a common finding in clients with hyperkalemia (potassium level of 5.8 mEq/L). Elevated potassium can lead to increased gastrointestinal motility and irritability, resulting in symptoms such as abdominal cramps and diarrhea.
C. Positive Chvostek's sign indicates hypocalcemia (low calcium levels) and is not associated with hyperkalemia. This sign reflects increased neuromuscular excitability due to low calcium levels, so it would not be expected in this scenario.
D. Decreased bowel motility is typically associated with hypokalemia (low potassium levels) rather than hyperkalemia. Elevated potassium levels can cause increased bowel motility and may lead to gastrointestinal symptoms like diarrhea and cramping. Therefore, decreased bowel motility would not be an expected finding in this case.

A. Provide the client with a glass of orange juice. B. Check the client's temperature. C. Instruct the client to take a brisk walk. D. Position the client on their left side.

Correct Answer is D

Explanation

A. Provide the client with a glass of orange juice. While orange juice can provide a quick source of sugar and may help if the client is experiencing low blood sugar, the symptoms of dizziness, racing heart, and pallor while lying on their back are more indicative of supine hypotensive syndrome. Therefore, addressing the positioning is more critical.
B. Check the client's temperature. Checking the client's temperature may provide some information but is not the most immediate action to take in response to the symptoms presented. The symptoms described are more related to positional changes rather than an infection or fever.
C. Instruct the client to take a brisk walk. Encouraging physical activity, especially brisk walking, is not appropriate given the client's symptoms. Walking may exacerbate feelings of dizziness and discomfort.
D. Position the client on their left side. Positioning the client on their left side helps relieve pressure on the inferior vena cava, which can occur when a pregnant client lies supine. This action can improve blood flow to the heart and the fetus, alleviating symptoms of dizziness, racing heart, and pallor. It is a recommended intervention for clients experiencing these symptoms in the second trimester.

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A nurse is obtaining a client's vital signs. Which of the following findings should the nurse report to the charge nurse?

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Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is reviewing a client's laboratory results. The client's potassium level is 5.8 mEq/L (3.5 to 5 mEq/L). Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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