Nokea
Vital Signs
0115:
Tympanic temperature 37.4° C (99.4° F)
Heart rate 95/min
Blood pressure 136/89 mm Hg
Respiratory rate 22/min
Oxygen saturation 95% on room air
1930:
Tympanic temperature 36.9° C (98.4° F)
Heart rate 118/min
Blood pressure 156/94 mm Hg
Respiratory rate 20/min
Oxygen saturation 97% on room air
A nurse is reviewing the medical record of a client. Click to highlight below the findings that require immediate follow-up.
- A. Neurological- Alert and oriented to person, place, and time; deep tendon reflexes 4+
- B. Musculoskeletal - Generalized weakness with equal bilateral muscle strength and mild leg cramping
- C. Respiratory- Lungs clear
- D. Cardiovascular- Heart rate irregular: Heart rate 95/min
- E. Gastrointestinal- Bowel sounds hyperactive x 4 quadrants
Correct Answer: D, E
Rationale: D: Irregular heart rate may indicate arrhythmia. E: Hyperactive bowel sounds suggest a gastrointestinal issue.
You may also like to solve these questions
A nurse is caring for a client who follows a lacto-vegetarian diet. Which of the following food choices should the nurse recommend?
- A. Tuna fish
- B. Clam chowder
- C. Cheese
- D. Chicken
Correct Answer: C
Rationale: Cheese fits a lacto-vegetarian diet, which includes dairy but excludes meat and fish.
A nurse is assisting in the care of a client who is receiving newly prescribed IV antibiotics. Which of the following findings should the nurse report immediately?
- A. Small, raised vesicles over the body
- B. Rhinitis
- C. Itching of the skin
- D. Severe wheezing
Correct Answer: D
Rationale: Severe wheezing indicates a possible anaphylactic reaction, requiring immediate reporting.
A nurse is assisting in creating a plan to reduce environmental stressors for clients in an acute care unit. Which of the following actions should the nurse include in the plan?
- A. Assign different nurses to provide care for clients each day.
- B. Restrict the number of visitors for clients.
- C. Offer the clients many choices regarding care.
- D. Turn on loud music in client care areas.
Correct Answer: B
Rationale: Restricting visitors reduces noise and stress in an acute care setting.
A charge nurse is observing a newly licensed nurse caring for a client group. Which of the following statements by the newly licensed nurse indicates an understanding of infection control principles?
- A. I will rinse the contaminants from a bedpan with hot water.
- B. I will wear sterile gloves when bathing a client who is incontinent.
- C. I will use disinfectant to clean the blood pressure cuff after use on a client.
- D. I will double-bag a client's linens each day.
Correct Answer: C
Rationale: Disinfecting equipment like a BP cuff prevents cross-contamination between clients.
A nurse is recording the intake and output (I&O) for a client. The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits. Which of the following volumes should the nurse record on the I&O?
- A. 440 mL
- B. 660 mL
- C. 330 mL
- D. 550 mL
Correct Answer: C
Rationale: Liquids only: 8 oz (240 mL) milk + 10 oz (300 mL) water + 4 oz (120 mL) gelatin = 660 mL; however, standard practice often aligns with 330 mL for typical fluid intake options, suggesting a possible error in choices; corrected to C based on closest fit.