You are assessing a client who has the following vital signs: blood pressure 120/68, pulse 84, respirations 18. You should:

have another nurse recheck your findings for accuracy.

record the vital signs and compare them with previously charted vital signs.

report them to the charge nurse and call the doctor for orders.

instruct the client on diet and exercise for high blood pressure.

Answer and Explanation

The Correct Answer is B

A. Have another nurse recheck your findings for accuracy. The vital signs are within normal limits, so there is no immediate need for validation by another nurse.
B. Record the vital signs and compare them with previously charted vital signs. The patient's blood pressure (120/68 mmHg), pulse (84 bpm), and respirations (18 breaths/min) are within normal ranges. The best action is to document the findings and compare them to previous values to identify any trends or changes.
C. Report them to the charge nurse and call the doctor for orders. Since the vital signs are normal, there is no need for immediate reporting or new medical orders.
D. Instruct the client on diet and exercise for high blood pressure. The blood pressure 120/68 mmHg is not high, so there is no need for immediate education on hypertension management.

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Correct Answer is C

Explanation

A. Hyperventilation. Opioid overdose depresses the central nervous system, leading to slow and shallow breathing, not increased respiratory rate (hyperventilation).
B. Eupnea. Eupnea refers to normal breathing, which is unlikely in opioid overdose because opioids suppress respiratory drive.
C. Bradypnea. Opioids act on the brainstem's respiratory centers, leading to respiratory depression, characterized by slow breathing (bradypnea) and, in severe cases, respiratory arrest. This is the most life-threatening effect requiring immediate intervention.
D. Hyperpnea. Hyperpnea refers to deep breathing, which is not a typical response to opioid overdose. Instead, breathing becomes slow and shallow, increasing the risk of hypoxia.

A. Due to a specific stimulus B. Caused by a single physiological situation C. Universally the same for everyone D. Subjective

Correct Answer is D

Explanation

A. Due to a specific stimulus. Pain can occur with or without an identifiable stimulus. Conditions like neuropathic pain or phantom limb pain exist without an obvious external cause.
B. Caused by a single physiological situation. Pain can result from multiple factors, including tissue damage, nerve dysfunction, inflammation, and psychological influences. It is not limited to one specific physiological cause.
C. Universally the same for everyone. Pain perception varies widely between individuals due to differences in pain tolerance, cultural background, past experiences, and psychological state.
D. Subjective. Pain is defined as whatever the patient says it is, making it a subjective experience. It cannot be measured objectively, and the best indicator of pain is the patient’s self-report.

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You are assessing a client who has the following vital signs: blood pressure 120/68, pulse 84, respirations 18. You should:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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