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:

Maintaining the head of the bed in a flat position is incorrect. The head of the bed should be elevated to reduce the risk of aspiration.

B reason:

Mixing the three medications together is incorrect. Medications should be administered separately to avoid potential interactions and ensure the correct dosage of each medication.

C reason:

Diluting each medication with tap water is not recommended. Sterile water or the water specified in the medication guidelines should be used for dilution to maintain safety and prevent contamination.

D reason:

Flushing the NG feeding tube with 30 ml of water immediately following medication administration is correct. This ensures that the medications are cleared from the tube and helps prevent tube blockage.

A. Remove all metal necklaces. B. Take several shallow breaths during the procedure. C. Do not eat or drink anything the morning of the test. D. Expect minor discomfort after the procedure.

Correct Answer is A

Explanation

A reason:

Removing all metal necklaces is correct because metal objects can interfere with the x-ray imaging. Metal can cause artifacts on the x-ray, making it difficult to interpret the results accurately. Therefore, clients are advised to remove any metal jewelry or accessories before the procedure.

B reason:

Taking several shallow breaths during the procedure is not correct. Clients are usually instructed to take a deep breath and hold it for a few seconds while the x-ray is being taken. This helps to get a clear image of the chest.

C reason:

Not eating or drinking anything the morning of the test is not necessary for a chest x-ray. This instruction is more relevant for certain other tests, such as blood tests or imaging studies requiring contrast. For a chest x-ray, there are no such restrictions.

D reason:

Expecting minor discomfort after the procedure is incorrect. A chest x-ray is a non-invasive and painless procedure. Patients typically do not experience any discomfort afterward.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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