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A nurse is reviewing vital signs obtained by an assistive personnel on a group of clients. The previous vital signs for each of the clients were obtained 4 hr earlier. Which of the following changes should the nurse identify as the priority finding?
- A. Heart rate change from 110/min to 68/min
- B. Respiratory rate change from 12/min to 20/min
- C. Blood pressure change from 118/78 mm Hg to 86/50 mm Hg
- D. Temperature change from 36.6°C (97.9°F) to 38.8°C (101.9°F)
Correct Answer: C
Rationale: Using the ABCs, blood pressure dropping from 118/78 to 86/50 mm Hg signals potential shock or hypoperfusion, a circulation emergency requiring immediate assessment. Heart rate falling from 110 to 68 could reflect recovery (e.g., post-tachycardia) or bradycardia, but without symptoms, it's less urgent. Respiratory rate rising from 12 to 20 suggests compensation or distress, but circulation trumps breathing in acuity here. Temperature jumping to 38.8°C indicates fever, possibly infection, but hemodynamic instability is more immediately life-threatening. A systolic drop to 86 mm Hg risks organ perfusion, aligning with triage priorities hypotension could stem from bleeding, dehydration, or sepsis, needing rapid provider notification. This finding drives urgent intervention, making it the nurse's top concern.
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A nurse is collecting data from a client who is perimenopausal. Which of the following findings is the priority for the nurse to report to the provider?
- A. Difficulty sleeping
- B. Hot flashes
- C. Vaginal dryness
- D. Urinary frequency
Correct Answer: D
Rationale: Perimenopause involves hormonal shifts causing various symptoms, but priority follows clinical urgency. Urinary frequency stands out it could indicate a urinary tract infection, bladder dysfunction, or even a gynecologic issue like prolapse, all requiring prompt evaluation. Difficulty sleeping, hot flashes, and vaginal dryness are classic perimenopausal symptoms from estrogen decline, managed symptomatically unless severe. Frequency, however, suggests a potential complication beyond hormonal changes, possibly impacting renal or pelvic health. Using the ABCs or Maslow's hierarchy, urinary issues tie to elimination needs, outranking sleep or comfort concerns. Reporting this ensures timely diagnosis (e.g., urinalysis) and treatment, preventing progression to pyelonephritis or chronic conditions, making it the most pressing finding to escalate.
A nurse is reinforcing teaching with a client who is newly diagnosed with dumping syndrome. Which of the following instructions should the nurse include in the teaching?
- A. Remain upright for 30 min after eating.
- B. Eat three large meals per day.
- C. Drink water with meals.
- D. Eliminate simple sugars.
Correct Answer: D
Rationale: Dumping syndrome occurs post-gastric surgery when food moves too quickly into the small intestine, causing nausea, diarrhea, and weakness. Eliminating simple sugars is key sugars draw fluid into the gut, worsening osmotic shifts and symptoms. Remaining upright helps slow gastric emptying but isn't the primary dietary fix. Eating three large meals overloads the stomach, triggering rapid dumping, whereas small, frequent meals are recommended. Drinking water with meals dilutes stomach contents, accelerating emptying and exacerbating symptoms; fluids should be taken between meals. Cutting simple sugars (e.g., candy, soda) reduces hyperosmolarity, stabilizes digestion, and aligns with evidence-based management, improving quality of life. This instruction empowers the client to control symptoms through diet, a cornerstone of dumping syndrome care, making it the most effective teaching point.
A nurse is collecting data from an older adult client who has cystitis. Which of the following findings should the nurse anticipate?
- A. Confusion
- B. Hypothermia
- C. Referred pain in the right shoulder
- D. Orange colored urine
- E. Fever
- F. Dysuria
- G. Urgency
Correct Answer: A
Rationale: Confusion is common in older adults with cystitis due to altered mental status from infection.
A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?
- A. Obtain blood pressure readings using the client's right arm.
- B. Limit range-of-motion exercises with the affected arm.
- C. Keep both arms below the level of the client's heart.
- D. Use the client's left arm to obtain blood samples.
- E. Elevate the right arm.
- F. Apply compression bandages.
- G. Avoid tight clothing.
Correct Answer: D
Rationale: Using the left arm prevents trauma to the right side, reducing lymphedema risk; BP on the affected arm increases risk.
A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following actions should the nurse take first?
- A. Use a fire extinguisher at the source of the smoke.
- B. Close the doors to the room and to the bathroom.
- C. Activate the fire alarm system.
- D. Assist the client to a nearby common area.
Correct Answer: D
Rationale: Assisting the client to safety is the first priority in a fire emergency per the RACE protocol (Rescue, Alarm, Contain, Extinguish).