The unlicensed assistive personnel reports vital signs for a patient to the nurse: Oral Temperature of 99.2 degrees Fahrenheit. Radial pulse of 88 bpm and regular, Respirations of 18 bpm and regular, blood pressure supine in left arm of 178/112 mm Hg. and oxygen saturation of 95% on room air. Which vital sign should the nurse be most concerned about?
Pulse
Temperature
Blood Pressure
Respirations
The Correct Answer is C
A. Pulse:
A pulse rate of 88 bpm is within the normal range. While it's important to monitor the pulse for changes, the reported pulse rate does not raise immediate concerns.
B. Temperature:
An oral temperature of 99.2 degrees Fahrenheit is within the normal range. While it's slightly elevated, it might be influenced by various factors, and isolated temperature readings are not as urgent as other vital signs.
C. Blood Pressure:
A blood pressure reading of 178/112 mm Hg is significantly elevated. High blood pressure is a major concern due to the potential risks it poses to the cardiovascular system, kidneys, and other organs. Immediate attention and further assessment are needed.
D. Respirations:
Respiratory rate of 18 bpm is within the normal range. While it's important to monitor respiratory rate, the reported rate does not raise immediate concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Perform oral hygiene at least every 2 hours:
Regular oral care is essential to maintain oral health, prevent infections, and provide comfort. When a client is NPO, and especially if they are weak or drowsy, the nurse should perform oral care at least every 2 hours to keep the oral cavity moist, reduce the risk of infection, and provide comfort.
B. Client must be supine with the head of the bed below 30 degrees:
Keeping the head of the bed elevated to at least 30 degrees is important for preventing aspiration and promoting respiratory function. This position is not specific to oral care but is a general guideline for managing clients at risk for aspiration.
C. Use alcohol-based mouth rinse with oral swab:
Alcohol-based mouth rinses can be drying and may not be suitable for a client who is NPO, as they might contribute to further dryness of the oral mucosa. Non-alcohol-based mouth rinses or moistened oral swabs are often preferred.
D. Assist the client with oral care by brushing their teeth twice daily:
While regular oral care is important, the frequency of twice daily brushing may not be sufficient for a weak, drowsy client, especially if they are NPO. Oral care should be performed more frequently to maintain oral hygiene.
Correct Answer is C
Explanation
A. 30 degrees:
This angle does not meet the criteria for a High Fowler's position, which requires a more upright position.
B. 15 to 20 degrees:
This angle is lower than what is generally considered as High Fowler's position. High Fowler's is a more upright position.
C. 90 degrees:
High Fowler's position involves elevating the head of the bed to 90 degrees. This position is often used for better lung expansion and respiratory function.
D. 45-60 degrees:
While this range is higher than a semi-Fowler's position, it is not as upright as the 90-degree elevation in a High Fowler's position.
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