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 C

Explanation

Yankauer catheter. A Yankauer catheter is a suction device used for oral suctioning. It is important for this client to have access to a Yankauer catheter for safe and effective suctioning of secretions from the mouth.

Option A is incorrect because an Oropharyngeal airway is used to maintain or open the airway.

Option B is incorrect because the water-soluble lubricant is used for lubricating the suction catheter during suctioning.

Option D is incorrect because sterile gloves are not routinely needed for suctioning.

Reasons why the other options are not answered: Option A: An oropharyngeal airway is not used for suctioning but is used to maintain an open airway in an unconscious patient. Option B: Water-soluble lubricant is used for lubricating the suction catheter during suctioning. Option D: Sterile gloves are not routinely needed for suctioning.

A. Bilateral tinnitus B. Difficulty swallowing C. Hypertension D. Petechial rash on the abdomen

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

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