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.

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Correct Answer is B

Explanation

A. A 3-year-old with fever, rash, and sore throat should be evaluated promptly, but these symptoms do not necessarily indicate an immediate life-threatening emergency.
B. A 45-year-old man with chest pain and diaphoresis for 1 hour is the priority because these are classic symptoms of acute coronary syndrome (ACS) or myocardial infarction (MI). Immediate emergency assessment and intervention are required.
C. A 14-year-old girl crying about a possible pregnancy needs emotional support and counseling but does not require immediate emergency intervention.
D. A 20-year-old man with a 3-inch shallow laceration on his leg needs wound care, but his condition is not life-threatening and does not require emergency assessment.

A. Malignancy B. Aneurysm C. Hernia D. Peritonitis

Correct Answer is D

Explanation

A. Malignancy can cause abdominal pain, but it does not typically present with acute sharp pain and involuntary guarding.
B. Aneurysms, particularly abdominal aortic aneurysms, may present with a pulsatile mass and deep, dull pain rather than sharp pain and guarding.
C. Hernias can cause pain, but they typically present with a bulging mass that increases with straining, not sharp pain with reflex guarding.
D. Peritonitis is correct because it causes severe abdominal pain, involuntary guarding, and rebound tenderness due to inflammation of the peritoneum. Reflex guarding is a protective mechanism indicating peritoneal irritation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which client would the nurse determine to be in most need of an emergency assessment?

Correct Answer is B

Explanation

While assessing a client's abdomen, the nurse observes sharp pains and involuntary reflex guarding on expiration. What complication does the nurse suspect based on these findings?

Correct Answer is D

Explanation

The nurse is assessing an older adult client in the emergency room. Upon assessment, the nurse notes that the client is in the tripod position, has dyspnea at rest, wheezing upon auscultation, and an oxygen saturation level of 91%. What significant health problem might the nurse suspect?

A client has sought care because they are concerned that a mole on the scalp may be skin cancer. Which finding would the nurse identify as being most suggestive of melanoma?

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?

A 40-year-old client is seen at the clinic with a headache and blurred vision that comes and goes. The client reports a pain of a 6 on a scale from 0–10. What question should the nurse ask to obtain more information about the pattern of the pain?

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?

An older adult client reports that they are experiencing severe trunk pain and is concerned that it might be shingles. Which type of lesion would the nurse most likely assess if shingles were present?

The nurse is caring for a client who has been diagnosed with colon cancer. When planning the client's care, the nurse should be aware of what function of the colon?