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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Telling the client to lay on the left side to prevent the tongue from falling back into the mouth is not a standard intervention for managing swallowing difficulties in Parkinson's disease. The focus should be on dietary modifications and safe swallowing techniques.
Choice B reason: Teaching the client to take medication an hour before meals to enhance the swallowing reflex is not a widely recognized intervention for managing swallowing difficulties. While timing of medication can be important, dietary adjustments are more immediately effective.
Choice C reason: Preparing the client and family for the future need of a gastrostomy tube for feeding might be necessary if swallowing difficulties progress significantly. However, it is not the first line of intervention and should be considered only after other measures have been tried.
Choice D reason: Encouraging the client and family to provide a semi-solid diet with thick liquids is the most appropriate intervention. Semi-solid and thickened liquids are easier to swallow and less likely to cause choking or aspiration, which is crucial for managing dysphagia in clients with Parkinson's disease.
Correct Answer is C
Explanation
Choice A reason: Carbidopa-levodopa does not primarily reduce the inflammatory process. Its main action is related to dopamine synthesis and availability.
Choice B reason: Carbidopa-levodopa does not slow scarring in the myelin sheath. This medication targets dopamine deficiency, not myelin health.
Choice C reason: Carbidopa-levodopa increases the amount of dopamine in the brain. Dopamine is a neurotransmitter that is crucial for motor control. Parkinson's disease is characterized by dopamine deficiency, and this medication helps to replenish dopamine levels, improving muscle function and reducing symptoms like tremors and stiffness.
Choice D reason: Carbidopa-levodopa is not an antiseizure medication. It is specifically used to manage the motor symptoms of Parkinson's disease by addressing dopamine deficiency.
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