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 A

Explanation

A. Baked chicken breast is relatively low in potassium compared to other options. A 3-ounce serving of baked chicken typically contains around 250-300 mg of potassium, making it a suitable choice for someone needing to limit their potassium intake due to an electrolyte imbalance.
B. Sweet potato is high in potassium, with a medium-sized sweet potato containing about 440 mg or more. This makes sweet potatoes an unsuitable choice for clients who need to monitor their potassium levels, especially in the case of hyperkalemia.
C. Orange juice is also high in potassium, with a single cup containing approximately 450 mg. Therefore, orange juice is not recommended for clients with potassium restrictions, as excessive potassium can lead to serious health complications.
D. Cantaloupe is another food that is high in potassium. A typical serving of cantaloupe contains around 400 mg of potassium, making it inappropriate for individuals who need to maintain low potassium levels. Thus, it is essential to choose foods that are lower in potassium to help manage electrolyte imbalances effectively.

A. Recommend the client spend time alone in his room. B. Offer the client low-protein snacks throughout the day. C. Encourage the client to use positive self-talk. D. Suggest the client exercise before going to bed.

Correct Answer is C

Explanation

A. Recommend the client spend time alone in his room. Social isolation can worsen depressive symptoms by increasing feelings of loneliness and hopelessness. Clients with major depressive disorder benefit from structured activities and social engagement, which help improve mood and prevent withdrawal.
B. Offer the client low-protein snacks throughout the day. Clients with depression may experience changes in appetite and energy levels, but protein is essential for neurotransmitter function and overall health. Instead of low-protein snacks, balanced meals with adequate nutrients should be encouraged to support physical and mental well-being.
C. Encourage the client to use positive self-talk. Negative thought patterns contribute to depressive symptoms, and cognitive-behavioral strategies such as positive self-talk help clients challenge and replace negative beliefs. Encouraging the client to engage in self-affirming statements can improve self-esteem and foster a more positive outlook.
D. Suggest the client exercise before going to bed. While exercise is beneficial for mood regulation and depression management, engaging in physical activity right before bedtime can lead to increased alertness, potentially disrupting sleep. Exercise is best scheduled earlier in the day to maximize its mood-enhancing and sleep-promoting effects.

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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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