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 B

Explanation

Choice A reason: Palpating the lymph nodes is not a standard technique for assessing early signs of rheumatoid arthritis. Lymph node enlargement can occur due to various reasons, but it is not specific to rheumatoid arthritis.

Choice B reason: Observing the client's fingers is crucial because early signs of rheumatoid arthritis often present in the small joints of the hands and fingers. Symptoms such as swelling, redness, stiffness, and deformities can be evident in these areas.

Choice C reason: Observing the skin for lesions is not specific to rheumatoid arthritis. While some skin conditions can be associated with autoimmune diseases, rheumatoid arthritis primarily affects the joints.

Choice D reason: Palpating large joints for nodules might be relevant in more advanced stages of rheumatoid arthritis, but early signs are typically observed in the small joints of the hands and fingers.

A. "I will wash my hands with warm soapy water before sticking my finger." B. "I will use a lancing device on the centre of my finger pad for a drop of blood." C. "I will inform the healthcare provider of my average haemoglobin A1C results weekly." D. "I will document my haemoglobin A1C results from the SMBG monitor every morning."

Correct Answer is A

Explanation

Choice A reason: Washing hands with warm soapy water before sticking the finger is a critical step in the process of self-monitoring blood glucose. Clean hands help prevent infections and ensure that the blood sample is not contaminated, which can affect the accuracy of glucose readings. This practice indicates that the client understands and can effectively follow the proper procedure for SMBG.

Choice B reason: Using a lancing device on the centre of the finger pad is not the correct technique. The sides of the finger pads are recommended for pricking because they are less sensitive than the centre and can provide a better sample with less discomfort. This indicates a misunderstanding of the correct procedure.

Choice C reason: Informing the healthcare provider of average haemoglobin A1C results weekly is unnecessary. Haemoglobin A1C is typically measured every 3 to 6 months to monitor long-term glucose control. Weekly reporting is not required and shows a lack of understanding about the appropriate use of A1C measurements.

Choice D reason: Documenting haemoglobin A1C results from the SMBG monitor every morning is incorrect. The SMBG monitor measures daily blood glucose levels, not haemoglobin A1C. Haemoglobin A1C provides an average blood glucose level over the past 2 to 3 months and is not obtained from daily SMBG readings.

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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?

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Naxlex Comprehensive Predictor Exams

Which technique should the nurse use when assessing for early signs of rheumatoid arthritis?

Correct Answer is B

Explanation

A client is newly diagnosed with type 2 diabetes mellitus. The nurse is educating the client about self-monitoring blood glucose (SMBG) and haemoglobin A1C. Which statement by the client indicates teaching has been effective?

Correct Answer is A

Explanation

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