Exhibits

Identify the findings at 1100, that require follow-up. Select all that apply.

T38.6° C (101.5° F), oral

Apical HR 108/min

BP 112/54 mm Hg, supine

R 22/min

Pulse oximetry 90% on 40% O2 via face mask

Mucous membranes pink.

Answer and Explanation

Correct Answer : A,B,C

A. T 38.6° C (101.5°F), oral. The client’s temperature has increased, which may indicate that the infection is progressing despite treatment. Persistent fever can contribute to dehydration, increased metabolic demand, and worsening systemic inflammation, all of which require further assessment and potential intervention.

B. Apical HR 108/min. The client’s heart rate has risen from 99/min to 108/min, which may be a compensatory response to fever, infection, or early signs of sepsis. Tachycardia combined with hypotension warrants close monitoring for worsening hemodynamic instability.

C. BP 112/54 mm Hg, supine. The blood pressure has decreased from 114/56 mm Hg to 112/54 mm Hg. While this is still within an acceptable range for some clients, the low diastolic pressure may indicate vasodilation due to sepsis or dehydration. If this trend continues or the client becomes symptomatic (e.g., dizziness, altered mental status), further intervention may be needed.

D. R 22/min. The respiratory rate has decreased from 32/min to 22/min, indicating improved respiratory status with oxygen therapy. This does not require follow-up as it falls within the normal range (12-20/min) and suggests a positive response to treatment.

E. Pulse oximetry 95% on 40% O₂ via face mask. The oxygen saturation has improved significantly from 85% on room air to 95% on supplemental oxygen. This suggests that oxygen therapy is effective, and no immediate follow-up is needed for this parameter.

F. Mucous membranes pink. The improvement from pale to pink mucous membranes indicates better oxygenation and perfusion, likely due to supplemental oxygen and improved respiratory function. This is a positive finding that does not require further intervention.

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Correct Answer is D

Explanation

A. Hypoglycemia. Acute pain does not directly cause hypoglycemia. While stress responses can influence blood sugar levels, pain typically triggers the release of catecholamines, which increase glucose levels rather than decrease them.

B. Bradycardia. Pain activates the sympathetic nervous system, leading to an increase in heart rate (tachycardia) rather than a decrease (bradycardia). Bradycardia is more commonly associated with parasympathetic activation or certain medications.

C. Decreased respiratory rate. Pain often causes an increase in respiratory rate (tachypnea) due to heightened sympathetic stimulation. A decreased respiratory rate would be more likely in cases of severe sedation or opioid overdose, not in response to acute pain.

D. Hypertension. Acute pain stimulates the release of stress hormones such as epinephrine and norepinephrine, leading to vasoconstriction and increased blood pressure. This is a common physiological response to pain as the body prepares to react to the perceived threat.

A. A client who is requesting a bedpan. B. A client who reports their IV pump is beeping. C. A client who is postoperative and is reporting nausea. D. A client who reports they have fallen while ambulating.

Correct Answer is D

Explanation

A. A client who is requesting a bedpan. While important for comfort and dignity, requesting a bedpan is not an urgent or life-threatening situation. The nurse should prioritize clients based on immediate safety concerns before assisting with toileting needs.

B. A client who reports their IV pump is beeping. An IV pump alarm may indicate an occlusion, low battery, or completion of an infusion. While it requires attention, it is not an immediate priority over a client who has experienced a fall, which could result in serious injuries.

C. A client who is postoperative and is reporting nausea. Nausea is discomforting and should be addressed, especially in postoperative clients who are at risk for aspiration. However, this is not an immediate safety concern compared to assessing a client who has fallen, which may involve head trauma or fractures.

D. A client who reports they have fallen while ambulating. A fall can result in serious injuries such as fractures, head trauma, or internal bleeding. The nurse must assess the client immediately for injuries, neurological status, and vital signs to determine the appropriate interventions, making this the highest priority.

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Exhibits Identify the findings at 1100, that require follow-up. Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who reports acute pain at a level of 7 on a scale of 0 to 10. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is caring for four clients who are all requesting assistance. Which of the following clients should the nurse assist first?

Correct Answer is D

Explanation

A nurse is teaching a class about the steps of the inflammatory response. The nurse should include that which of the following is the first step in the inflammatory response?

Exhibits Identify the findings at 1100, that require follow-up. Select all that apply.

A nurse administers the wrong medication to a client. After assessing the client, the nurse contacts the provider and completes an incident report. Which of the following components of professionalism is the nurse demonstrating?

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A nurse is discussing factors that influence communication with a group of newly licensed nurses. Which of the following information should the nurse include?

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Exhibits

Identify the findings at 1100, that require follow-up. Select all that apply.