A nurse is reviewing vital signs obtained by an assistive personnel on a group of clients. The previous vital signs for each of the clients were obtained 4 hours earlier. Which of the following changes should the nurse identify as the priority finding?

Temperature change from 36.6° C (97.8° F) to 38.8° C (101.9° F).

Respiratory rate change from 12/min to 20/min.

Blood pressure change from 118/78 mm Hg to 86/50 mm Hg.

Heart rate change from 110/min to 68/min.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C: Blood pressure change from 118/78 mm Hg to 86/50 mm Hg.

Choice C rationale: A significant drop in blood pressure can indicate various serious conditions, such as shock, hemorrhage, or a severe infection. The nurse should assess the client further and intervene as necessary to prevent complications.

Choice A rationale: The change in temperature may indicate the onset of a fever and requires further assessment, but it is not as immediately concerning as the sudden drop in blood pressure.

Choice B rationale: The change in respiratory rate could be a result of factors like pain, anxiety, or exercise. While it warrants further assessment, it is not as critical as the blood pressure change.

Choice D rationale: The heart rate change may be a response to medications, rest, or other factors. It should be monitored and assessed, but the priority finding is the blood pressure change, which may indicate a more severe underlying issue.

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Correct Answer is D

Explanation

Occupational therapist. Disuse syndrome is a condition that occurs when a person experiences a reduction in physical activity, resulting in a decline in physical function. An occupational therapist can help the client improve their ability to perform daily activities and improve their overall functioning. A social worker can help the client and their family with emotional and social issues related to the condition. An herbalist is not necessary for the management of disuse syndrome. A dietitian can help the client with their nutritional needs but may not address their physical functioning.

A. "Take a shower rather than a tub bath." B. "Avoid climbing stairs for 8 weeks." C. "Douche with warm water to remove vaginal discharge." D. "Expect bright red vaginal bleeding for 1 week following surgery."

Correct Answer is A

Explanation

The correct answer is choice A, "Take a shower rather than a tub bath." This is a safety precaution to prevent infection . Choice B is incorrect because clients are encouraged to walk around after surgery to prevent blood clots. Choice C is incorrect because douching after surgery can increase the risk of infection. Choice D is incorrect because bright red vaginal bleeding after surgery warrants a followup with a healthcare provider. Choice B is not correct because clients are encouraged to walk around after surgery to prevent blood clots. Choice C is not correct because douching after surgery can increase the risk of infection. Choice D is not correct because bright red vaginal bleeding after surgery warrants a followup.

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A nurse is reviewing vital signs obtained by an assistive personnel on a group of clients. The previous vital signs for each of the clients were obtained 4 hours earlier. Which of the following changes should the nurse identify as the priority finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has disuse syndrome following cast removal from a lower extremity. Which of the following referrals should the nurse include in the plan of care?

Correct Answer is D

Explanation

A nurse is reinforcing discharge teaching with a client who had an abdominal hysterectomy 2 days ago. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

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