An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 88/58 mm Hg. Which of the following vital signs should the nurse re-measure?

Respiratory rate.

Temperature.

Pulse rate.

BP.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Re-measuring the respiratory rate is unnecessary. The reported respiratory rate falls within the normal range of 12-20 breaths per minute for adults.

Choice B rationale:

Re-measuring the temperature is the correct action. Tympanic temperature measurements can be influenced by factors such as earwax buildup, ear infection, or improper placement of the thermometer. Repeating the temperature measurement ensures accuracy.

Choice C rationale:

Re-measuring the pulse rate is unnecessary. The reported pulse rate of 92 beats per minute falls within the normal range of 60-100 beats per minute for adults.

Choice D rationale:

Re-measuring the blood pressure is unnecessary. The reported blood pressure of 88/58 mm Hg, while at the lower end of the normal range (typically around 90/60 mm Hg), is not excessively low and doesn't indicate an immediate need for concern.

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Correct Answer is D

Explanation

Choice A rationale:

A macular rash on the chest and back is not indicative of a paradoxical drug reaction to lorazepam, a benzodiazepine. Paradoxical reactions involve unexpected and opposite responses to a medication, such as increased agitation and excitement instead of the intended calming effect. A rash is not consistent with this type of reaction.

Choice B rationale:

Increased appetite is not associated with a paradoxical drug reaction to lorazepam. Paradoxical reactions involve behavioral and physiological responses that are contrary to the expected effects of the medication. Increased appetite does not fit this pattern.

Choice C rationale:

Drowsiness and mild sedation are the intended effects of lorazepam, a benzodiazepine. Paradoxical reactions are characterized by unexpected and opposite responses. Drowsiness and mild sedation align with the expected pharmacological actions of benzodiazepines, making this choice incorrect for a paradoxical reaction.

Choice D rationale:

Increased agitation and insomnia are indicative of a paradoxical drug reaction to lorazepam. Benzodiazepines like lorazepam are central nervous system depressants and are commonly used to treat anxiety and promote sedation. However, in some cases, paradoxical reactions can occur, leading to increased agitation, excitement, and even insomnia. These reactions are thought to be more common in children and older adults. This choice is correct because it aligns with the characteristics of a paradoxical reaction.

A. "Do not adjust the oxygen flow rate.” B. "Check your oxygen equipment once each week.” C. "Store unused oxygen tanks horizontally.” D. "Use wool blankets on your bed.”

Correct Answer is A

Explanation

Choice A rationale:

Instructing the client not to adjust the oxygen flow rate is crucial to ensure the appropriate amount of oxygen is delivered. Oxygen flow rates are prescribed by a healthcare provider based on the client's needs, and altering the flow rate without medical guidance can lead to inadequate oxygen delivery or oxygen toxicity.

Choice B rationale:

Weekly equipment checks are important, but this choice is not the most critical instruction. Clients should be instructed to check their oxygen equipment daily for proper functioning and to address any issues promptly. Waiting a whole week could lead to potential problems going unnoticed.

Choice C rationale:

Storing unused oxygen tanks horizontally is incorrect. Oxygen tanks should be stored upright to prevent leaks and ensure proper functioning. Storing them horizontally can cause valve damage and leakage, which could lead to hazards.

Choice D rationale:

Using wool blankets on the bed is not a suitable instruction for a client using oxygen therapy. Wool blankets can generate static electricity, which might pose a fire hazard in the presence of oxygen-enriched environments.

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An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 88/58 mm Hg. Which of the following vital signs should the nurse re-measure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is given lorazepam, a benzodiazepine, to decrease symptoms of anxiety and restlessness on the evening prior to planned surgery. The nurse knows that the patient is experiencing a paradoxical drug reaction when which of the following is assessed?

Correct Answer is D

Explanation

A Medical-Surgical nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

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