Given the following vital signs, which should the nurse address first in the patient?
Blood pressure 118/76 mm Hg, heart rate 92/min, temperature 38.1° C (100.6° F), oxygen saturation 95% on room air.
Blood pressure 126/84 mm Hg, heart rate 104/min, respiratory rate 24/min, temperature 38.5 C (101.3* F), oxygen saturation 92% on room air.
The Correct Answer is B
Choice A rationale
The vital signs presented in this choice are within the normal range. A blood pressure of 118/76 mm Hg is considered normal. A heart rate of 92/min is slightly elevated but still within the normal range (60-100 beats per minute). A temperature of 38.1° C (100.6° F) indicates a slight fever, which could be a response to an infection or inflammation. An oxygen saturation of 95% on room air is within the normal range (95%-100%).
Choice B rationale
The vital signs presented in this choice indicate that the patient may be experiencing a respiratory issue. A blood pressure of 126/84 mm Hg is slightly elevated but still within the acceptable range. A heart rate of 104/min is high, indicating that the heart is working harder than normal. A respiratory rate of 24/min is also high, suggesting that the patient may be having difficulty breathing. A temperature of 38.5 C (101.3* F) indicates a fever, which could be a response to an infection. An oxygen saturation of 92% on room air is below the normal range (95%-100%), suggesting that the patient is not getting enough oxygen. This is the vital sign that should be addressed first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A regular diet would be too heavy for a patient who had gastric bypass surgery the day before.
Choice B rationale
A clear liquid diet is typically recommended for patients who had gastric bypass surgery the day before. This diet includes broths and unsweetened juices.
Choice C rationale
A full liquid diet may be introduced after a few days post-surgery, not the day after.
Choice D rationale
A mechanical soft diet is typically introduced weeks after surgery, not the day after.
Correct Answer is A
Explanation
A. Stop the antibiotic infusion immediately and notify the healthcare provider.
- Explanation: This is the correct first action. The client is showing signs of a severe allergic reaction, possibly anaphylaxis. Stopping the antibiotic prevents further exposure to the allergen, and notifying the provider ensures prompt medical intervention.
B. Apply a cool compress to the itchy areas and monitor for further reactions.
- Explanation: While a cool compress may help with itching, it does not address the serious symptoms of anaphylaxis, such as difficulty swallowing and wheezing. Immediate action is required beyond just symptom management.
C. Administer diphenhydramine (Benadryl) as a first-line treatment.
- Explanation: While antihistamines like diphenhydramine are helpful in treating mild allergic reactions, this case suggests anaphylaxis, which requires epinephrine as the first-line treatment. Administering diphenhydramine alone is not sufficient for airway compromise.
D. Assess the client’s throat for swelling and encourage them to drink water.
- Explanation: Assessing for throat swelling is important, but encouraging oral intake is not appropriate when a client has difficulty swallowing, as this could worsen airway obstruction. The priority is stopping the medication and seeking emergency intervention.
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