Name: Samantha Green
Provider: G. Panie, MD
Code Status: Full Code
Allergies: None known
Age: 45 years
Weight: 120.6 kg (265.32 b)
The nurse obtains a client's vital signs. Which vital sign(s) should the nurse find concerning? Select all that apply.
|
Temperature |
102.3 F (39 C) |
|
Heart Rate |
110 |
|
Respiratory Rate. |
19 |
|
Blood Pressure |
86/56 |
|
Oxygen Saturation |
95% on room air |
|
Pain |
2/10 Lower back |
Blood pressure
Temperature
Oxygen saturation
Heart rate
Respiratory rate
Pain
Correct Answer : A,B,D
A. Blood pressure 86/56 mmHg is hypotensive for an adult. Normal adult blood pressure is typically around 120/80 mmHg, and values this low can indicate impaired perfusion to vital organs, which may result from dehydration, sepsis, heart failure, or blood loss. Hypotension in combination with other abnormal vitals such as fever and tachycardia increases the concern for systemic compromise. The nurse should assess for signs of poor perfusion, including altered mental status, cool extremities, and delayed capillary refill, and notify the provider promptly.
B. Temperature 102.3°F (39°C) indicates a febrile state, which is clinically significant. Fever may be a sign of infection, inflammation, or other systemic illness. In combination with hypotension and tachycardia, this raises concern for early sepsis, a potentially life-threatening condition. The nurse should monitor trends, obtain cultures if ordered, and implement interventions to control the fever and address the underlying cause.
C. Oxygen saturation 95% on room air is generally within normal limits for most adults, as normal SpO₂ is typically 95–100%. Although slightly lower than ideal in some high-risk clients, this value does not require immediate intervention and is not as concerning as the other abnormal vitals.
D. Heart rate 110 bpm is tachycardic, as the normal adult range is 60–100 bpm. Tachycardia in this context may represent a compensatory mechanism in response to hypotension, fever, or early infection. Persistent or worsening tachycardia warrants close monitoring and further evaluation to determine underlying causes such as hypovolemia, sepsis, pain, or anxiety.
E. Respiratory rate 19 is within the normal adult range of 12–20 breaths per minute. Although monitoring should continue, this value is not immediately concerning.
F. Pain 2/10 is mild and does not indicate a physiologic emergency. While pain assessment and management are important for comfort and healing, this level of pain is not a priority concern in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E"]
Explanation
A. The difference between the systolic and diastolic pressures is referred to as the pulse pressure, calculated by subtracting diastolic from systolic pressure (e.g., 140 – 90 = 50 mmHg). While pulse pressure provides useful information about arterial compliance and stroke volume, it does not define systolic pressure itself. Therefore, this statement does not reflect correct understanding of the systolic reading.
B. The pressure in the veins when the ventricles are contracting is incorrect. Venous pressure is generally low and does not fluctuate significantly with ventricular contraction, unlike arterial pressure. Systolic pressure is measured in the arteries, not veins, so this option demonstrates a misunderstanding.
C. The pressure in the veins when the ventricles are pushing blood forward is also incorrect for the same reason. Venous pressure is largely influenced by venous return and right atrial pressure, not the force of ventricular contraction. Systolic pressure refers exclusively to arterial pressure during ventricular contraction, not venous pressure.
D. The pressure in the arteries when the ventricles are pushing blood forward is correct. During ventricular systole, the left ventricle contracts, propelling blood into the aorta and systemic arteries, which creates the highest pressure in the arterial system. This peak arterial pressure is recorded as the systolic value in a blood pressure reading.
E. The pressure in the arteries when the ventricles are contracting is also correct. “Contracting” is another way of describing ventricular systole. Systolic pressure represents the maximum arterial pressure generated during this phase of the cardiac cycle, making this statement accurate.
Correct Answer is B
Explanation
A. Pulling the pinna forward and up does not effectively straighten the adult ear canal. The external auditory canal in adults has a natural upward and forward curve, so pulling forward does not properly align the canal for visualization of the tympanic membrane.
B. In adults (and children older than 3 years), the nurse should pull the pinna up and back when inserting the otoscope. This maneuver straightens the S-shaped external auditory canal, allowing clear visualization of the tympanic membrane. Proper positioning reduces discomfort and prevents injury during the examination.
C. Pulling the pinna down and back is appropriate for infants and young children under 3 years of age. In this age group, the ear canal is shorter and more horizontal. Using this technique on an adult would not properly align the canal.
D. Leaving the pinna in its natural position does not straighten the ear canal, making visualization of the tympanic membrane more difficult and potentially uncomfortable for the client.
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