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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Lime ice popsicle.
Choice A rationale:
Orange juice is acidic and can irritate the stomach lining, which is not ideal for someone recovering from gastroenteritis.Acidic foods and drinks can exacerbate symptoms like nausea and stomach pain.
Choice B rationale:
Cream of broccoli soup is not recommended because it is a dairy-based product.Dairy can be difficult to digest and may worsen symptoms like diarrhea and stomach cramps during the recovery phase of gastroenteritis.
Choice C rationale:
Lime ice popsicle is a good choice because it is a clear liquid that can help with hydration and is easy on the stomach.Ice popsicles can also help soothe the throat and provide a small amount of sugar for energy without overwhelming the digestive system.
Choice D rationale:
Vanilla pudding, although soft, contains dairy, which can be hard to digest for someone recovering from gastroenteritis.Dairy products can lead to further gastrointestinal discomfort.
Correct Answer is ["D","E"]
Explanation
Running cool water over the affected area will help to decrease pain and prevent further tissue damage. Allowing the affected area to remain open to air will help to promote healing and prevent infection.
A. "Apply ice to the larger blisters" is an incorrect answer because applying ice can cause further damage to the skin and delay healing.
B. "Administer ibuprofen for pain" is an incorrect answer because the nurse cannot administer medications without a physician's order.
C. "Maintain skin integrity over the blisters" is an incorrect answer because maintaining skin integrity over the blisters can cause further damage and delay healing.
Explanation: The nurse should run cool water over the affected area and allow it to remain open to the air to promote healing and prevent infection. Applying ice or medication without a physician's order can cause further damage and delay healing.
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