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:

Decreasing the temperature in the client's room is incorrect. The client is already hypothermic and needs to be warmed, not further cooled.

B reason:

Requesting a prescription for an antipyretic medication is inappropriate. Antipyretics are used to lower fever, not to treat hypothermia.

C reason:

Placing a cooling fan near the client is incorrect and would exacerbate hypothermia.

D reason:

Placing a warming blanket over the client is correct. This action helps to gradually raise the client's body temperature to a safe level.

A. The client should hold the cane on the weak side of his body. B. The grip should be level with the client's waist. C. When the client moves, he should move the cane forward first. D. The client should first move the strong leg, then the weak one.

Correct Answer is C

Explanation

A reason:

The client should hold the cane on the strong side, not the weak side. This provides better support and stability when ambulating.

B reason:

The grip of the cane should be level with the client's wrist crease, not the waist. This ensures proper ergonomic support and reduces the risk of strain or injury.

C reason:

When the client moves, he should move the cane forward first. This provides support and stability before taking a step with the weaker leg.

D reason:

The client should first move the weak leg, not the strong one. The cane and the weak leg should move together to provide support and balance during ambulation.

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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

A nurse is caring for a client who has a rectal temperature of 35°C (95°F). Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the clients use of a cane?

Correct Answer is C

Explanation

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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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