Which client assessment should a nurse immediately report to the health care provider?
Report of joint pain by a client who recently started taking arthritis medication.
Report of decreased appetite and difficulty sleeping in a recently widowed client.
Weight loss of two pounds in a client admitted in congestive heart failure.
Diminished breath sounds in a client admitted with pneumonia.
The Correct Answer is D
This is because diminished breath sounds indicate poor oxygenation and ventilation, which can lead to respiratory failure and hypoxia. The healthcare provider should be notified immediately to assess the client and provide appropriate interventions.
Choice A is wrong because joint pain is a common side effect of some arthritis medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs). It does not require immediate attention unless it is severe or accompanied by other symptoms, such as swelling, redness, or fever.
Choice B is wrong because decreased appetite and difficulty sleeping are normal responses to grief and loss. They do not indicate a medical emergency, but rather a need for emotional support and counseling.
Choice C is wrong because a weight loss of two pounds in a client admitted with congestive heart failure is a positive sign that indicates fluid removal and improved cardiac function. It does not require immediate reporting, but rather ongoing monitoring and evaluation.
Normal ranges for vital signs are as follows :
- Blood pressure: 90/60 mm Hg to 120/80 mm Hg
- Breathing: 12 to 18 breaths per minute
- Pulse: 60 to 100 beats per minute
- Temperature: 97.8°F to 99.1°F (36.5°C to 37.3°C); average 98.6°F (37°C)
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This needle size is appropriate for an intramuscular injection into the deltoid of a 175-pound adult male with a viscous fluid.
The needle length should be long enough to reach the muscle through the subcutaneous tissue, and the needle gauge should be suitable for the viscosity of the fluid. A 23-gauge needle is a common choice for intramuscular injections.
Choice A is wrong because a 1/2 inch needle is too short to reach the deltoid muscle in an adult male.
Choice C is wrong because a 1-1/2 inch needle is too long and may cause injury to the underlying nerves or blood vessels.
Choice D is wrong because a 16-gauge needle is too large and may cause excessive tissue trauma and pain.
Correct Answer is D
Explanation
Levofloxacin (Levaquin) is a fluoroquinolone antibiotic that is not structurally related to penicillin and has a very low risk of cross-reactivity with penicillin.
Levofloxacin can be safely used in patients with penicillin allergy unless they have a history of hypersensitivity to other fluoroquinolones.
Choice A is wrong because cephalexin (Keflex) is a first-generation cephalosporin that has a similar side chain to some penicillins and may cause cross-reactivity in penicillin-allergic patients. The risk of cross-reactivity is higher for first- and second-generation cephalosporins than for third- and fourth-generation cephalosporins.
Choice B is wrong because cefaclor (Ceclor) is a second-generation cep
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