The unlicensed assistive personnel (UAP) recorded the vital signs of four clients. Which client needs immediate nursing intervention? (SEE HANDOUT- PRIORITY VITAL SIGNS)

Exhibits

Answer and Explanation

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.

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Correct Answer is ["A","B","D","E"]

Explanation

A. Choose a cuff that is the right size. Using the correct cuff size is essential for accurate blood pressure readings. A cuff that is too small can falsely elevate readings, while a cuff that is too large can falsely lower them.
B. Support the extremity. The arm should be supported at heart level to prevent unnecessary muscle strain, which could affect blood pressure readings. An unsupported arm may lead to an artificially higher reading.
C. Have the patient cross their legs while taking blood pressure. Crossing the legs can increase blood pressure by reducing venous return and increasing vascular resistance, leading to inaccurate measurements. The patient should keep their feet flat on the floor.
D. Ensure proper cuff application. The cuff should be placed snugly around the upper arm with the artery marker positioned correctly over the brachial artery. Improper placement can lead to inaccurate readings.
E. Ensure that the patient is sitting or lying. Blood pressure should be measured while the patient is in a stable position—either sitting with feet flat on the floor or lying down. Standing may result in postural changes that can alter blood pressure readings.

A. In the morning B. During periods of stress C. After exercising D. In the preoperative period

Correct Answer is A

Explanation

A. Body temperature follows a circadian rhythm, typically being lowest in the early morning (around 4–6 AM) and peaking in the late afternoon or evening.
B. Stress activates the sympathetic nervous system, which increases metabolic activity and raises body temperature rather than lowering it.
C. Physical activity generates heat, leading to an increase in body temperature, not a decrease.
D. While some surgical preparations involve cooling the patient, body temperature is not naturally lower before surgery. Instead, preoperative anxiety may even cause a slight increase in temperature.

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The unlicensed assistive personnel (UAP) recorded the vital signs of four clients. Which client needs immediate nursing intervention? (SEE HANDOUT- PRIORITY VITAL SIGNS) Exhibits

Nursing Test Bank

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Exhibits Lamont the procedure, but she also wants to explain some important concepts. What should she include? Select the 4 correct answers, (Case Study #1)

Correct Answer is ["A","B","D","E"]

Explanation

When evaluating the client's temperature levels, the nurse expects the client's temperature to be lower:

Correct Answer is A

Explanation

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The unlicensed assistive personnel (UAP) recorded the vital signs of four clients. Which client needs immediate nursing intervention? (SEE HANDOUT- PRIORITY VITAL SIGNS) Exhibits

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3 FL OZ =

The unlicensed assistive personnel (UAP) recorded the vital signs of four clients. Which client needs immediate nursing intervention? (SEE HANDOUT- PRIORITY VITAL SIGNS)

Exhibits