The nursing student is obtaining the patient's vital signs (VS). The patient has gone to the clinic seeking help because she is having chest pain. Which of the following vital signs are most important to obtain?
Temperature, pulse, respirations, BP
Temperature, pulse, respirations, BP, pain
BP. respirations, temperature, pulse
Temperature, pulse, respirations, blood pressure, O2 sat, pain
The Correct Answer is D
A. Temperature, pulse, respirations, BP. While these are standard vital signs, they do not include oxygen saturation or pain level, both of which are critical in a patient with chest pain.
B. Temperature, pulse, respirations, BP, pain. Pain is an essential assessment, especially for chest pain, but oxygen saturation should also be measured to assess for hypoxia, which can contribute to cardiac symptoms.
C. BP, respirations, temperature, pulse. This option omits both oxygen saturation and pain level, which are essential in evaluating cardiac and respiratory function in a patient presenting with chest pain.
D. Temperature, pulse, respirations, blood pressure, O2 sat, pain. This option includes all critical assessments for a patient with chest pain. Oxygen saturation helps assess respiratory and circulatory efficiency, and pain assessment is vital in determining the severity and possible cause of the chest pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.5"]
Explanation
Calculation:
Volume to administer = Dose ordered/ Dose available
Given:
- Ordered dose = 75 mg
- Available concentration = 50 mg/mL
Volume = 75mg/ (50mg/mL)
= 1.5mL
Thus, the nurse will administer 1.5 mL.
Correct Answer is B
Explanation
A. Have another nurse recheck your findings for accuracy. The vital signs are within normal limits, so there is no immediate need for validation by another nurse.
B. Record the vital signs and compare them with previously charted vital signs. The patient's blood pressure (120/68 mmHg), pulse (84 bpm), and respirations (18 breaths/min) are within normal ranges. The best action is to document the findings and compare them to previous values to identify any trends or changes.
C. Report them to the charge nurse and call the doctor for orders. Since the vital signs are normal, there is no need for immediate reporting or new medical orders.
D. Instruct the client on diet and exercise for high blood pressure. The blood pressure 120/68 mmHg is not high, so there is no need for immediate education on hypertension management.
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