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: The DASH eating plan does not recommend excluding grains from the daily diet. In fact, whole grains are an important part of the DASH diet.

Choice B reason: Enjoying fat-free yogurt as an occasional snack food aligns with the DASH diet's emphasis on low-fat dairy products. This behaviour indicates adherence to the dietary guidelines for reducing hypertension.

Choice C reason: Using lactose-free dairy products is not specifically related to the DASH diet. It may be relevant for individuals who are lactose intolerant, but it does not indicate adherence to the DASH diet principles.

Choice D reason: Carefully cleaning and peeling fresh fruits and vegetables is a good practice for food safety but does not specifically indicate adherence to the DASH diet. The DASH diet encourages the consumption of fruits and vegetables, but how they are cleaned and prepared is less relevant than the overall dietary choices.

A. Evaluate for evidence of incontinence. B. Observe for lacerations to the tongue. C. Document details of the seizure activity. D. Observe for prolonged periods of apnoea.

Correct Answer is D

Explanation

Choice A reason: Evaluating for evidence of incontinence is important for understanding the full scope of the seizure's impact on the client. However, it is not the first priority immediately after a seizure. Ensuring the client's airway and breathing status takes precedence.

Choice B reason: Observing for lacerations to the tongue is relevant as it can indicate the severity of the seizure and the potential for airway obstruction. However, the most critical intervention immediately after the seizure is to assess the client's breathing and ensure they are not experiencing prolonged apnoea.

Choice C reason: Documenting the details of the seizure activity is necessary for medical records and future treatment planning. While it is important, it is not the immediate priority. The nurse must first ensure the client's safety and physiological stability.

Choice D reason: Observing for prolonged periods of apnoea is the most urgent intervention. Apnoea, or a pause in breathing, can lead to hypoxia and other serious complications if not addressed immediately. Ensuring that the client is breathing properly is the top priority after a seizure.

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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

The nurse is evaluating a client's understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behaviour indicates that the client is adhering to the eating plan?

Correct Answer is B

Explanation

While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

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