The nurse is obtaining vital sign measurements every 15 minutes for a client who had an emergency appendectomy and currently has a temperature of 101.4°F (38.6°C). Which vital sign measurements should the nurse report to the healthcare provider?

Heart rate 80 beats/minute, respirations 18 breaths/minute, and blood pressure 140/70 mmHg.

Heart rate 110 beats/minute, respirations 22 breaths/minute, and blood pressure 88/56 mmHg.

Heart rate 62 beats/minute, respirations 19 breaths/minute, and blood pressure 150/90 mmHg.

Heart rate 100 beats/minute, respirations 24 breaths/minute, and blood pressure 118/68 mmHg.

Answer and Explanation

The Correct Answer is B

Choice A reason: These vital signs are within normal limits and do not indicate an immediate concern that requires reporting to the healthcare provider.

Choice B reason: This set of vital signs shows a heart rate of 110 beats/minute, which is tachycardia, and a blood pressure of 88/56 mmHg, which is hypotension. Both of these findings, combined with the client's fever, could indicate sepsis or other complications that require immediate attention.

Choice C reason: These vital signs are relatively stable and do not indicate a critical issue that requires immediate reporting.

Choice D reason: While these vital signs show an elevated respiratory rate, they are not as critical as the vital signs in Choice B, which show hypotension and tachycardia.

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Correct Answer is A

Explanation

Choice A reason: Taking a walk with the client is an effective intervention for addressing agitation and restlessness in a client with Alzheimer's disease. Physical activity can help reduce anxiety and agitation, and walking provides a safe and structured way for the client to expend energy while being closely supervised.

Choice B reason: Sitting the client in a recliner may provide temporary comfort, but it does not address the underlying agitation and restlessness. The client may still attempt to leave the room and become more frustrated if their movement is restricted.

Choice C reason: Administering a sleeping medication can have sedative effects, but it should not be the first-line intervention for agitation and restlessness in clients with Alzheimer's disease. Non-pharmacological approaches, such as walking, should be tried first. Sedatives can also increase the risk of falls and other complications.

Choice D reason: Moving the client to a locked unit may be necessary for safety in some cases, but it should not be the initial intervention for agitation and restlessness. The goal is to use less restrictive interventions first to manage the client's behaviour.

A. Haematocrit of 30% (0.30 volume fraction). B. Facial puffiness and periorbital enema. C. Further decline in level of consciousness. D. Cold and dry skin.

Correct Answer is C

Explanation

Choice A reason: A haematocrit of 30% is below the normal range and indicates anaemia, which is common in hypothyroidism. However, it does not require immediate intervention compared to a decline in consciousness.

Choice B reason: Facial puffiness and periorbital enema are common signs of hypothyroidism but do not require immediate intervention. They are more indicative of chronic, rather than acute, issues.

Choice C reason: A further decline in level of consciousness is critical and warrants immediate action. It can indicate a myxoedema coma, a severe complication of hypothyroidism that is life-threatening and requires urgent treatment.

Choice D reason: Cold and dry skin is a common symptom of hypothyroidism but does not require immediate intervention compared to a decline in consciousness.

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The nurse is obtaining vital sign measurements every 15 minutes for a client who had an emergency appendectomy and currently has a temperature of 101.4°F (38.6°C). Which vital sign measurements should the nurse report to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the evening shift, a client with Alzheimer's disease becomes agitated, restless, and repeatedly attempts to leave the room unattended. Which intervention should the nurse implement?

Correct Answer is A

Explanation

A client who has a history of hypothyroidism was admitted with lethargy and confusion. Which additional finding warrants immediate action by the nurse?

Correct Answer is C

Explanation

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