The nurse has collected the vital signs on a client who has been on bedrest for a week and just returned from physical therapy. See chart:

- Blood Pressure: 122/84 mmHg

- Heart Rate: 108

- Respiratory Rate: 22

- Oxygen Saturation: 96% on room air

- Temperature: 98.0°F

What action should the nurse take?

Document the client's bradycardia.

Apply oxygen via nasal cannula at 2 liters per minute.

Reassess the vital signs in five minutes.

Notify the provider of the findings.

Answer and Explanation

The Correct Answer is C

A. Documenting bradycardia is incorrect because the client is experiencing tachycardia (HR 108), not bradycardia.
B. Applying oxygen at 2L/min is incorrect because the oxygen saturation is normal (96% on room air). Oxygen therapy is not indicated at this time.
C. Reassess the vital signs in five minutes is correct because the slightly elevated heart rate and respiratory rate may be due to recent physical activity after prolonged bedrest. It is important to allow the client time to recover and reassess before taking further action.
D. Notifying the provider is incorrect because there is no immediate concern; the elevated HR and RR are expected post-activity.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Consulting clinical resources is helpful but should be done after reviewing the client’s specific information.
B. Performing a mini overview of body systems occurs during the assessment, not before meeting the client.
C. Gathering materials is important but comes after understanding the client’s history.
D. Reviewing the client’s medical record is correct because it helps the nurse gather baseline information, understand past medical history, and prepare for the assessment effectively.

A. "The care team needs to cross-reference your diagnostic testing with your medical history." B. "In general, it's necessary for us to gather as much information about each client as possible." C. "We do not want to focus solely on the medical problem that brought you here." D. "This information will help me to plan individualized nursing care with you."

Correct Answer is D

Explanation

A. While diagnostic testing and medical history are important, this response does not acknowledge the client’s frustration or emphasize the purpose of the assessment.
B. This response is too general and does not provide reassurance to the client.
C. While this statement is true, it does not clearly explain why the history is necessary in a way that involves the client.
D. "This information will help me to plan individualized nursing care with you" is correct because it directly explains the purpose of the assessment and involves the client in their care.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to meet a client and perform a comprehensive health assessment. Which action should the nurse perform first?

Correct Answer is D

Explanation

The nurse is completing a health history on a client who is upset about having to answer questions. The client states, "Can't we just focus on my problem!" How should the nurse respond to the client regarding the need to gather this data?

Correct Answer is D

Explanation

The nurse is inspecting a new client's abdomen and notes the presence of a tight, distended abdomen and visible arterioles on the abdominal skin surface. What would the nurse do next?

A 15-year-old boy shows the school nurse a bump on his neck. The nurse observes a raised, erythematous, solid, 0.3-by-0.2 cm mass. How would the nurse document this finding?

A 45-year-old client with dark skin tone comes to the clinic complaining of fatigue, thirst, and frequent urination. During the examination, the nurse notices areas of hyperpigmentation around the neck and in the axillae. What is the priority intervention by the nurse?

The nurse is assessing vital signs and is preparing to measure the client's blood pressure. Prior to obtaining the blood pressure, what action would be most appropriate?

A nurse has completed the review of systems component of the client's health history. Which assessment finding should the nurse document under the review of systems?

What is the primary purpose of a nursing health assessment?

A nurse is auscultating a client's lungs during the initial assessment of the patient in the emergency room. The nurse hears wheezes on expiration in the lower posterior lobes bilaterally. Which of the following actions should the nurse do first?