The nurse is caring for a client who presented to the emergency room with BP of 138/90, HR of 110, O2 Sat of 95%, Temp of 38°C, and abdominal pain level of 7/10. Which of the above vital signs would the nurse address first?

Blood pressure of 138/90

Heart rate 110 beats per minute

O2 Sat of 95%

Temperature 38°C

Answer and Explanation

The Correct Answer is B

A reason:

A blood pressure of 138/90 is elevated but not immediately life-threatening. It is important to monitor, but it is not the highest priority in this situation.

B reason:

A heart rate of 110 beats per minute is the most concerning and should be addressed first. Tachycardia can indicate pain, fever, or other underlying issues that need prompt attention.

C reason:

An O2 Sat of 95% is within normal limits and is not an immediate concern compared to the other vital signs presented.

D reason:

A temperature of 38°C indicates a fever, which needs to be addressed, but the elevated heart rate takes priority as it can have more immediate implications for the client's condition.

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Correct Answer is D

Explanation

A reason:

Having a cup of hot cocoa immediately before bedtime is not advisable as it contains caffeine, which can interfere with sleep. Herbal teas or warm milk are better alternatives to promote relaxation and sleep.

B reason:

Walking briskly for 30 minutes before bedtime can be stimulating rather than relaxing. While regular exercise is beneficial for sleep, it is best performed earlier in the day. Exercise close to bedtime can increase alertness and make it harder to fall asleep.

C reason:

Doing muscle relaxation techniques each afternoon is beneficial, but the focus should be on practicing these techniques before bedtime to help wind down and prepare for sleep. Afternoon relaxation is good but not directly related to sleep promotion.

D reason:

Avoiding alcohol before bedtime is correct. Although alcohol may initially make one feel drowsy, it can disrupt sleep patterns and reduce sleep quality. Abstaining from alcohol before bed is a positive step toward improving sleep.

A. I will place an area rug at the entry of my bathroom. B. I will keep the fluorescent ceiling light on in my room at night. C. I will place a bath seat in my shower to use when I bathe. D. I will keep my walker at the end of my bed.

Correct Answer is C

Explanation

A reason: I will place an area rug at the entry of my bathroom. Placing an area rug at the entry of the bathroom can be a tripping hazard, especially for a client with a history of falls. Rugs can slip or bunch up, increasing the risk of falls, making this statement incorrect for ensuring home safety.

B reason: I will keep the fluorescent ceiling light on in my room at night. Keeping a light on at night can help prevent falls by improving visibility, especially during trips to the bathroom. However, it is not as directly related to fall prevention as other measures like using assistive devices or securing trip hazards. This statement is less focused on the primary prevention strategy.

C reason: I will place a bath seat in my shower to use when I bathe. Using a bath seat is an effective fall prevention strategy in the shower, where surfaces are often slippery. A bath seat provides stability and support, reducing the risk of falls while bathing. This indicates a clear understanding of home safety measures for fall prevention.

D reason: I will keep my walker at the end of my bed. While keeping a walker within reach is important, placing it at the end of the bed may not be the most convenient or safest location. Ideally, the walker should be easily accessible from where the client gets in and out of bed. This statement does not show the best understanding of optimal safety practices.

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The nurse is caring for a client who presented to the emergency room with BP of 138/90, HR of 110, O2 Sat of 95%, Temp of 38°C, and abdominal pain level of 7/10. Which of the above vital signs would the nurse address first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

Correct Answer is C

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