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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Conducting a client care conference is important for multidisciplinary care planning, but it may not immediately address the client's safety needs upon admission. Safety measures should be implemented promptly to prevent potential accidents or confusion.

Choice B reason: Providing information about advance directives is crucial for ensuring that the client's wishes are respected during their care. However, this does not directly address immediate safety concerns that may arise from being in a new environment.

Choice C reason: Orienting the client to his room is essential to promote client safety. This includes familiarizing the client with the layout of the room, location of the bathroom, call bell, and any other essential features. It helps prevent falls and accidents by reducing confusion and ensuring the client knows how to access help if needed.

Choice D reason: Developing a plan of care is critical for long-term management of the client's health needs. However, immediate safety concerns should be addressed first to ensure a safe environment for the client from the outset.

A. Client information when possible. B. Triage priority. C. Next of kin information. D. Decontamination if applicable. E. Medications and treatments administered.

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A reason: Including client information on the disaster tag is crucial for identification and tracking purposes. This information ensures that each client can be accurately identified, which is essential for providing appropriate care and for communication with family members and other healthcare providers.

Choice B reason: Triage priority is an essential piece of information that indicates the level of urgency for each client's care. This prioritization helps healthcare providers quickly identify which clients need immediate attention and which can wait, thereby optimizing the use of limited resources during a mass casualty incident.

Choice C reason: Next of kin information is important for contacting family members and loved ones in case of emergency. This information is essential for communicating the client's status, obtaining additional medical history, and providing support to the family during a stressful time.

Choice D reason: Decontamination information, if applicable, indicates whether the client has undergone decontamination procedures. This is critical for ensuring that contaminated clients do not pose a risk to others, including healthcare providers and other patients, and for maintaining a safe environment within the healthcare facility.

Choice E reason: Documenting medications and treatments administered is vital for continuity of care. This information allows healthcare providers to track what treatments have been given, avoid duplication of medications, and monitor the client's response to treatment. It also ensures that any subsequent healthcare providers have a complete record of the client's care.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing the admission process for an older adult client new to the unit. After gathering the assessment data and reviewing the health history, which of the following best promotes client safety?

Correct Answer is C

Explanation

The emergency department nurse is triaging clients arriving from a mass casualty incident. During the triage, the nurse confirms that each client has a disaster tag. What information should be placed on the tag for each client? (Select all that apply)

Correct Answer is ["A","B","C","D","E"]

Explanation

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