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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. 74-year-old female with malnutrition and a foley catheter in place:

Malnutrition can weaken the immune system, making the individual more susceptible to infections. Additionally, the presence of a foley catheter increases the risk of urinary tract infections.

B. 54-year-old female admitted for chest pain observation:

Chest pain observation does not inherently increase the risk of infection.

C. 34-year-old male admitted for seizure observation:

Seizure observation does not inherently increase the risk of infection.

D. 78-year-old male with right-sided hemiplegia following a stroke:

While the hemiplegia following a stroke may pose mobility challenges, the presence of malnutrition and a foley catheter in option A puts the patient at a higher risk for infection.

A. The nurse should place his or her feet close together side by side to make themselves have a good center of gravity to assist the patient to the floor. B. The nurse should rock his or her pelvis out and try to hold the patient up to prevent falling. C. The nurse should grasp the gait belt and push the client’s body backward away from his or her body. D. The nurse should use the patients gait belt to gently slide the client down his or her body to the floor.

Correct Answer is D

Explanation

A. Placing the nurse's feet close together side by side to have a good center of gravity:

While maintaining a good center of gravity is important, in a falling situation, it's crucial to prioritize the client's safety over the nurse's stability. This option doesn’t address the prevention of the client’s fall.

B. Rocking the nurse's pelvis out and trying to hold the patient up to prevent falling:

Attempting to hold the patient up during a fall may put both the nurse and the client at risk of injury.

C. Grasping the gait belt and pushing the client’s body backward away from the nurse's body:

Pushing the client backward could cause the client to lose balance and fall in an uncontrolled manner.

D. Using the patient's gait belt to gently slide the client down the nurse's body to the floor:

This is the recommended action as it allows for a controlled descent to the floor, minimizing the impact of the fall and reducing the risk of injury to both the client and the nurse.

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Naxlex Comprehensive Predictor Exams

The nurse would recognize which of the following patients would be at highest risk for developing an infection?

Correct Answer is A

Explanation

A nurse is ambulating a client who catches her foot on the bed frame and begins to fall. Which of the following is an accurate step to prevent or minimize damage from this fall?

Correct Answer is D

Explanation

The nurse on the progressive care unit is preparing to perform a sterile wet to dry dressing change on a client with a sacral pressure ulcer. The nurse notes that the sterile saline at the bedside is marked as opened 48 hours ago. What is the nurse’s priority action?

Which of the following interventions would best assist the nurse in breaking the chain of infection for all clients?

The physician’s admitting orders indicate that the client is to be placed in a High Fowler’s position. Upon positioning this client, how much will the nurse elevate the head of the bed?

A nurse is providing oral care to a client with dentures. What action would the nurse do first?

During a physical assessment a nurse inspects a patient’s abdomen. What assessment technique would the nurse perform next?

The nurse is taking a radial pulse and assessing the pulse amplitude for a patient. Documentation by the nurse states. “Pulses are +3 in the upper extremities.” What amplitude is the nurse assessing?