The unlicensed assistive personnel (UAP) recorded the vital signs of four clients. Which client needs immediate nursing intervention? (SEE HANDOUT- PRIORITY VITAL SIGNS)
B
A
D
C
The Correct Answer is C
Client A has normal vital signs except for a mild fever, no urgent intervention needed.
Client B shows mild tachycardia and increased respiratory rate, but oxygen saturation and blood pressure remain stable, requires monitoring but not immediate action.
Client C has fever, tachycardia, and tachypnea, suggesting infection or dehydration. While assessment is needed, the patient is not in immediate distress compared to Client D.
Client D requires immediate nursing intervention due to the following critical findings: Bradycardia which may indicate poor perfusion, conduction abnormalities, or medication side effects, bradypnea can signal respiratory depression or impending failure, hypotension suggests shock or decreased perfusion, which may lead to organ failure and hypoxia, oxygen saturation below 90% is a critical finding and requires immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
A. Pulse of smooth contour with 2+ amplitude. A normal pulse should have a smooth upstroke and downstroke with a moderate (2+) amplitude, indicating adequate blood flow and cardiac function.
B. Heart rate of 62 beats/min. A normal resting heart rate for a healthy adult range from 60 to 100 beats per minute. A heart rate of 62 bpm is within this normal range.
C. S1 and S2 present with regular rhythm. The first (S1) and second (S2) heart sounds should be audible and regular, indicating normal closure of the heart valves and a steady cardiac rhythm.
D. Mild, pedal edema. Pedal edema is not a normal finding in a healthy adult and may indicate fluid retention or cardiovascular issues such as heart failure or venous insufficiency.
Correct Answer is D
Explanation
A. Listening as the patient inhales and then going to the next site during exhalation. This method does not allow for a complete assessment of breath sounds, as abnormalities may be present during either phase of respiration.
B. If the patient is modest, listening to sounds over his or her clothing or hospital gown. Clothing can muffle or distort breath sounds, leading to inaccurate assessments. The stethoscope should be placed directly on the skin.
C. Instructing the patient to breathe in and out rapidly while listening to the breath sounds. Rapid breathing may lead to hyperventilation and dizziness, and it can make it difficult to detect subtle abnormalities such as crackles or wheezes.
D. Listening to at least one full respiration in each location. This is the correct technique because it allows the nurse to fully assess breath sounds during both inhalation and exhalation, ensuring accurate identification of any abnormal sounds.
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