The nurse is assessing a mechanically ventilated client with pneumonia after providing deep oral suctioning to the client. Which assessment finding would be unexpected and be a priority for the nurse to address?
Heart rate of 104 bpm
Tympanic temperature of 102.6°F (39.2°C)
Blood pressure of 158/90 mmHg
Respiratory rate of 24 breaths/min
The Correct Answer is B
Choice A reason: A heart rate of 104 bpm can be expected in a client with pneumonia and after suctioning. Tachycardia (elevated heart rate) can occur as a response to infection, stress, or the suctioning procedure itself. While it should be monitored, it is not the most critical finding.
Choice B reason: A tympanic temperature of 102.6°F (39.2°C) is unexpected and indicates a significant fever, which may suggest a worsening infection or sepsis. This finding requires immediate attention as it could indicate that the current treatment for pneumonia is not effective, and the client's condition may be deteriorating.
Choice C reason: A blood pressure of 158/90 mmHg, though elevated, may be less critical in the context of this client's condition. Hypertension can occur due to various factors, including stress and illness, and should be monitored but is not the most urgent priority compared to a high fever.
Choice D reason: A respiratory rate of 24 breaths/min is slightly elevated but can be expected in a client with pneumonia and after suctioning. This rate indicates mild tachypnea, which should be monitored but is not as immediately concerning as a high fever.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Administering tube feedings to a quadriplegic client is a task that typically requires specialized training and knowledge to ensure it is performed safely and correctly. This task is often reserved for licensed nursing personnel due to the potential complications that can arise, such as aspiration or incorrect tube placement. Therefore, it is not appropriate to delegate this task to unlicensed assistive personnel (UAP).
Choice B reason: Assisting with bowel training by placing the client on the bedside commode is an appropriate task to delegate to unlicensed assistive personnel. This task involves providing physical assistance and support to the client, which falls within the scope of practice for UAP. It does not require specialized nursing knowledge or skills, making it suitable for delegation.
Choice C reason: Observing the client demonstrating a self-catheterization technique is a task that requires clinical judgment and assessment skills to ensure the client is performing the procedure correctly and safely. This responsibility is typically within the scope of practice for licensed nurses rather than UAP.
Choice D reason: Teaching Crede's maneuver to a client needing to void involves providing instruction and education on a specific technique to assist with bladder emptying. This teaching role requires specialized knowledge and skills, making it more appropriate for licensed nursing personnel. It is not suitable for delegation to UAP.
Correct Answer is D
Explanation
Choice A reason: Veracity is the principle of truthfulness and honesty. It involves providing accurate information to clients and being truthful in communication. While important in healthcare, veracity does not specifically address the nurse's failure to ensure the client's safety after administering a narcotic.
Choice B reason: Autonomy refers to respecting the client's right to make their own decisions about their care. While autonomy is a fundamental ethical principle, the scenario involves the nurse's responsibility to ensure safety, which falls under a different principle.
Choice C reason: Beneficence is the principle of acting in the best interest of the client by promoting good and preventing harm. Although related to the scenario, beneficence focuses more on the proactive aspect of providing care rather than preventing harm resulting from inaction.
Choice D reason: Nonmaleficence is the ethical principle of "do no harm." The nurse violated this principle by discharging the client without ensuring they had a designated driver, leading to a motor vehicle collision and injuries. The nurse's action indirectly caused harm, violating the principle of nonmaleficence.
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