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

knee-chest. During sigmoidoscopy, the client should lie on their left side with their right knee flexed slightly. The nurse should then position the client in the knee-chest (Sims) position, where the client leans forward with bent knees and support the chest and forearms on the table or a pillow. This allows better visualization and access to the rectal area for the sigmoidoscopy procedure.

An explanation for incorrect choices:

A. Orthopneic position is upright sitting with arms and elbows resting on a table or on a pillow, which helps clients who have difficulty breathing; it is not suitable for sigmoidoscopy.

B. Trendelenburg position

is supine with the head lower than the feet, which can cause blood flow to the head and increased intracranial pressure; it is not suitable for sigmoidoscopy.

C. Prone position is lying face down, which is not suitable for sigmoidoscopy.

A. Decreased calcium levels. B. Increased serum glucose levels. C. Absent bowel sounds. D. Intermittent abdominal pain.

Correct Answer is B

No explanation

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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 preparing a client for a sigmoidoscopy. In which of the following positions should the nurse place the client?

Correct Answer is D

Explanation

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Correct Answer is B

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