The unlicensed assistive personnel (UAP) working in a small community hospital obtains 0800 vital sign measurements of clients on the unit. In reviewing these vital signs, which measurement warrants immediate intervention by the practical nurse?
An older adult with a blood pressure of 140/88 mm Hg.
An adult who has a respiratory rate of 18 breaths/minute.
A preschooler with an oral temperature of 98.2° F (36.7° C).
A one-month-old infant with a heart rate of 80 beats/minute.
The Correct Answer is D
A. An older adult with a blood pressure of 140/88 mm Hg: This blood pressure is slightly elevated but is common in older adults. It does not require immediate intervention unless accompanied by other concerning symptoms like chest pain or altered mental status.
B. An adult who has a respiratory rate of 18 breaths/minute: A respiratory rate of 18 is within the normal adult range (12–20 breaths/minute) and does not suggest respiratory distress or require urgent intervention.
C. A preschooler with an oral temperature of 98.2° F (36.7° C): This temperature is normal for a preschooler, and no immediate action is needed as it falls well within the expected range for healthy children.
D. A one-month-old infant with a heart rate of 80 beats/minute: A normal heart rate for a one-month-old infant ranges from about 100–160 beats per minute. A heart rate of 80 is dangerously low (bradycardia) for an infant and warrants immediate intervention to assess for respiratory or cardiac compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Have you experienced anxiety or anger?": Feelings of anxiety and anger are common in anticipatory grief, but while important, they do not represent the most urgent safety concern compared to assessing for suicidal ideation.
B. "Have you been able to perform daily activities?": Evaluating functional status is important but is not the highest priority when first assessing a client’s emotional and psychological response to a terminal diagnosis.
C. "Have you had suicidal thoughts?": Assessing for suicidal ideation is the highest priority because clients facing a terminal illness may experience overwhelming despair. Ensuring the client’s immediate safety must come before addressing emotional support or coping mechanisms.
D. "Have you joined any support groups?": Participation in support groups is helpful for emotional healing, but determining the client's current mental health status and safety must be addressed before exploring support resources.
Correct Answer is D
Explanation
A. Apply lotion to sacrum: Applying lotion may help with general skin hydration but does not directly address pressure relief, which is the primary intervention needed to prevent worsening of a stage one pressure injury.
B. Use wet-to-dry dressings daily: Wet-to-dry dressings are used for wounds with necrotic tissue that need debridement. A stage one pressure injury involves intact skin without an open wound, so such dressings are not appropriate.
C. Elevate head of bed 30 degrees: Elevating the head of the bed slightly can reduce aspiration risk but also increases pressure on the sacrum if maintained for long periods. Position changes are more critical to relieve sacral pressure.
D. Change positions every 2 hours: Repositioning every two hours is essential to relieve pressure on the sacrum and promote circulation. This practice helps prevent progression of the pressure injury and is a cornerstone of effective pressure ulcer prevention.
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