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Which findings reflect vital signs that are concerning and require further nursing monitoring and intervention? Select all that apply.
- A. After albuterol administration, 5-year-old client has a pulse of 120/min and reports tremor
- B. After hydromorphone 1 mg IV push, blood pressure decreases from 130/80 mm Hg to 110/70 mm Hg
- C. Blood pressure is 90/60 mm Hg, and the nurse is preparing to administer prescribed nifedipine
- D. Blood pressure was 120/80 mm Hg and pulse was 80/min before blood transfusion, current values are 90/70 mm Hg and 100/min, respectively
- E. Fetal heart rate monitored during labor decreases from 140/min to 100/min following a contraction
Correct Answer: C,D,E
Rationale: Hypotension (90/60 mm Hg) with nifedipine risks severe hypotension. Transfusion-related hypotension and tachycardia suggest a reaction. Fetal heart rate deceleration post-contraction indicates potential distress. Albuterol's tachycardia/tremor and hydromorphone's mild BP drop are expected.
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A client is being admitted with a diagnosis of active shingles with a disseminated rash. Which room assignment is most appropriate for this client?
- A. A private room with contact and droplet precautions
- B. A private room with negative airflow and contact and airborne precautions
- C. A private room with positive airflow and airborne precautions
- D. A semi-private 2-bed room with standard precautions
Correct Answer: B
Rationale: Disseminated shingles in immunocompromised clients requires contact and airborne precautions due to varicella-zoster virus transmission risk. A private room with negative airflow prevents spread. Droplet or standard precautions are insufficient, and positive airflow is inappropriate.
A client is admitted for treatment of a right upper lobe infiltrate and to rule out tuberculosis. Which of these would be the most appropriate self-protective action by the nurse?
- A. Provide negative room ventilation
- B. Wear a face mask with shield
- C. Wear a particulate respirator mask
- D. Institute airborne precautions
Correct Answer: C
Rationale: Tight fitting, high-efficiency masks are required when caring for clients who have a suspected communicable disease of the airborne variety.
Prior to discharge from the postanesthesia care unit following a vein stripping of the left leg, the nurse should tell the client to:
- A. apply heat to the affected leg for 10 minutes out of every hour for the next 24 hours.
- B. sit with the legs up or walk but avoid prolonged standing and sitting with the feet down.
- C. avoid weight bearing on the affected leg for the next week.
- D. remove the compression bandages after 24 hours.
Correct Answer: B
Rationale: Elevating legs or walking promotes venous return, while avoiding prolonged standing/sitting prevents stasis post-vein stripping. Heat, non-weight bearing, and early bandage removal are not recommended.
The nurse is caring for a client with Kawasaki disease. Which of the following actions would be a priority for the nurse to take?
- A. Monitor the client for gallop heart sounds and decreased urine output.
- B. Provide a quiet, nonstimulating, restful environment for the client.
- C. Apply cool compresses to the skin of the client's hands and feet.
- D. Offer the client soft foods and adequate amounts of clear liquids.
Correct Answer: B
Rationale: A quiet, restful environment reduces irritability and stress in Kawasaki disease, promoting recovery. Monitoring heart sounds/urine output is secondary, as cardiac complications are less immediate. Cool compresses and soft foods are less critical.
An elderly client has a 17-mm induration after a tuberculin skin test. Based on this result, which statement is most accurate?
- A. The client has a false-positive reaction due to advanced age
- B. The client has a tuberculosis infection
- C. The client has active tuberculosis disease
- D. The client must be isolated immediately
Correct Answer: B
Rationale: A 17-mm induration in an elderly client indicates TB infection, as the threshold is ≥10 mm for high-risk groups. It doesn't confirm active disease, which requires further testing (e.g., chest X-ray). False positives are possible but not assumed based on age alone. Isolation isn't required without active disease.