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.

Answer and Explanation

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)

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Correct Answer is C

Explanation

Orthostatic hypotension noted with dangling.

This means that the client’s blood pressure drops when changing position from lying down to sitting or standing. This can cause symptoms such as paleness, sweating, rapid pulse, weakness, and dizziness.

The nurse should document this finding and report it to the physician.

Choice A is wrong because a normal reaction to a position change would not cause such severe symptoms.

Choice B is wrong because the gait belt applied is not a finding but an intervention.

Choice D is wrong because elevated blood sugar probable is not a finding but a speculation.

Choice E is wrong because spot accucheck obtained is not a finding but an action.

Choice F is wrong because fear of falling expressed by a client is not a finding related to the client’s vital signs or physical condition.

Choice G is wrong because provided reassurance is not a finding but a nursing measure.

A. When the client exhibits physiologic symptoms of pain. B. Prior to painful activities, such as bathing. C. On a regular schedule around the clock. D. Whenever the client requests it.

Correct Answer is C

Explanation

On a regular schedule around the clock. This is because when pain is present for more than 12 hours a day, analgesic dosages are best administered around the clock rather than on an as-needed basis.

Choice A is wrong because waiting for the client to exhibit physiologic symptoms of pain may delay the administration of analgesics and cause unnecessary suffering. Physiologic symptoms of pain are not always reliable indicators of pain intensity or quality.

Choice B is wrong because administering analgesics prior to painful activities may not provide adequate pain relief throughout the day. Painful activities may vary depending on the client’s condition and preferences.

Choice D is wrong because relying on the client’s request may not ensure optimal pain management. Some clients may be reluctant to ask for analgesics due to fear of addiction, side effects, or being perceived as weak.

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Which client assessment should a nurse immediately report to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is getting a client out of bed to ambulate for the first time. The client is pale, diaphoretic, has a pulse of 100/minute, and says, “I feel weak. Let me sit on the side of the bed for a minute.” What finding should the nurse document?

Correct Answer is C

Explanation

For optimal pain management, when is the best time to administer prescribed analgesics for a client who had abdominal surgery 12 hours ago?

Correct Answer is C

Explanation

A client newly diagnosed with schizophrenia asks the nurse “Will I pass this disease on to my children?” What is the best response?

Which action should a nurse perform when administering an intramuscular injection via the Z- track method?

A client has lorazepam prescribed before surgery and refuses the injection. If the nurse administers the scheduled injection despite the client’s lack of consent, which term best describes the nurse’s action?

A nurse should include which statement when instructing a client about Transcranial Magnetic Stimulation (TMS).

Which statement, if made by a client diagnosed with sleep disturbance, should a nurse evaluate as correct understanding of the plan of care to improve sleep patterns?

Which assessment finding would be considered normal in an elderly client?

Which technique is the proper method to administer otic drops to an adult client?