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. Make sure the bed is low, locked, and the call light is in reach of the patient:
This action is crucial for preventing falls. A low bed reduces the risk of injury if the client were to accidentally fall. Locking the bed prevents unintended movement, and ensuring the call light is within reach allows the client to call for assistance if needed.
B. Ask the client if they have ordered their dinner:
While nutrition is important, it is not the immediate priority after assisting the client back to bed. Safety measures should be addressed first.
C. Educate the client on the surgical procedure they are scheduled for in the morning:
While pre-operative education is important, it is not the immediate concern after assisting the client back to bed. Safety measures for the current situation take precedence.
D. Check that the client is wearing non-skid socks while in bed:
While wearing non-skid socks is a safety measure, ensuring the bed is low, locked, and the call light is accessible is a more immediate and critical action after assisting the client back to bed.
Correct Answer is A
Explanation
A. Increased, strong:
A pulse amplitude of +3 indicates an increased or strong pulse. This suggests a forceful and palpable pulse, potentially associated with conditions like fever, anemia, or increased cardiac output.
B. Diminished, weaker than expected:
This would typically be associated with a lower than normal pulse amplitude. It might suggest poor peripheral perfusion or decreased cardiac output.
C. Absent, unable to palpate:
If the pulse is absent or unable to be palpated, it could indicate severe conditions such as vascular occlusion or cardiac arrest.
D. Bounding:
A bounding pulse is one with a forceful and strong amplitude. It suggests a powerful expansion of the arterial wall, and it can be associated with conditions like fever, anemia, or increased cardiac output.
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