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 B
Explanation
A. Report the injury to a nurse manager:
While reporting the incident is important, the immediate action to take is cleaning the affected area to minimize the risk of infection.
B. Wash the affected area with soap and water:
This is the immediate priority to reduce the risk of potential infection or transmission of any contaminants from the needlestick injury.
C. Report the needle stick to the infection control department:
Reporting the incident is essential, but it should follow the immediate step of cleaning the affected area to prevent infection.
D. Scrub the area with hand sanitizer for a full 2 minutes:
Hand sanitizer may not be as effective as soap and water in removing contaminants from a needlestick injury site. Washing with soap and water is more appropriate for cleaning the area.
Correct Answer is A
Explanation
A. Defining the legal scope of nursing practice:
The nurse practice act in each state defines the scope of practice for nurses, outlining what nurses can and cannot do within the legal boundaries of their profession. It specifies the duties, responsibilities, and limitations of nursing practice within that particular state.
B. Lobbying federal lawmakers to advance professional nursing:
While nursing organizations and associations may engage in lobbying efforts at the federal level, it's not a direct component of the state's nurse practice act.
C. Providing continuing education programs:
While states might require nurses to participate in continuing education for license renewal, the provision of continuing education programs itself is not a direct element of the nurse practice act.
D. Creating institutional policies for health care practices:
Institutional policies are typically developed by healthcare institutions or organizations and are separate from the state's nurse practice act.
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