Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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 hours earlier. Which of the following changes should the nurse identify as the priority finding?
A. Temperature change from 36.6° C (97.8° F) to 38.8° C (101.9° F).
The change in temperature may indicate the onset of a fever and requires further assessment, but it is not as immediately concerning as the sudden drop in blood pressure.
B. Respiratory rate change from 12/min to 20/min.
The change in respiratory rate could be a result of factors like pain, anxiety, or exercise. While it warrants further assessment, it is not as critical as the blood pressure change.
C. Blood pressure change from 118/78 mm Hg to 86/50 mm Hg.
A significant drop in blood pressure can indicate various serious conditions, such as shock, hemorrhage, or a severe infection. The nurse should assess the client further and intervene as necessary to prevent complications.
D. Heart rate change from 110/min to 68/min.
The heart rate change may be a response to medications, rest, or other factors. It should be monitored and assessed, but the priority finding is the blood pressure change, which may indicate a more severe underlying issue.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Adult Med Surg 2020 with NGN Proctored Exam. Take the full exam now
Full Explanation
The correct answer is choice C: Blood pressure change from 118/78 mm Hg to 86/50 mm Hg.
Choice C rationale: A significant drop in blood pressure can indicate various serious conditions, such as shock, hemorrhage, or a severe infection. The nurse should assess the client further and intervene as necessary to prevent complications.
Choice A rationale: The change in temperature may indicate the onset of a fever and requires further assessment, but it is not as immediately concerning as the sudden drop in blood pressure.
Choice B rationale: The change in respiratory rate could be a result of factors like pain, anxiety, or exercise. While it warrants further assessment, it is not as critical as the blood pressure change.
Choice D rationale: The heart rate change may be a response to medications, rest, or other factors. It should be monitored and assessed, but the priority finding is the blood pressure change, which may indicate a more severe underlying issue.
Similar Questions
A nurse in an urgent care facility is collecting data from a client who was stung by a wasp. Which of the following findings indicates the client is experiencing anaphylaxis?
A. Bilateral tinnitus
B. Difficulty swallowing
difficulty swallowing. Anaphylaxis is a severe and potentially life-threatening allergic reaction that affects multiple bodily systems, including the respiratory, cardiovascular, and gastrointestinal systems. Difficulty swallowing or swelling in the throat or mouth is a hallmark sign of anaphylaxis. Other signs and symptoms of anaphylaxis include hives, itching, redness, anxiety or confusion, rapid weak pulse
C. Hypertension
D. Petechial rash on the abdomen
A nurse is caring for a client who has partial-thickness burns on 50% of his body and is receiving total parenteral nutrition. The nurse should actively monitor the client for which of the following?
A. Decreased calcium levels.
B. Increased serum glucose levels.
Increased serum glucose levels. Total parenteral nutrition (TPN) can cause hyperglycemia as it provides a concentrated source of glucose to the bloodstream. Monitoring serum glucose levels is important to detect and intervene early if trends of hyperglycemia occur. Decreased calcium levels may indicate an electrolyte imbalance, not a result of TPN. Absent bowel sounds and intermittent abdominal pain may indicate a gastrointestinal problem
C. Absent bowel sounds.
D. Intermittent abdominal pain.
A nurse is reinforcing teaching with a client who has diabetes mellitus about reducing the risk for a stroke. Which of the following statements by the client indicates an understanding of the teaching?
A. "My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke."
B. "I can decrease my risk for a stroke by losing excess weight."
. "I can decrease my risk for a stroke by losing excess weight." Losing excess weight is an important lifestyle modification that can help reduce the risk of stroke in people with diabetes mellitus. Glucocorticoids are not generally used as a preventative measure for stroke. HbA1c levels that are 6 percent or less indicate good glucose control and are not necessarily associated with an increased risk of stroke. Having a total cholesterol level below 200 mg/dL does not increase the risk for stroke; in fact, it may help reduce the risk. Choice A: Glucocorticoids are not generally used as a preventative measure for stroke. Choice C: HbA1c levels that are 6 percent or less indicate good glucose control and are not necessarily associated with an increased risk of stroke. Choice D: Having a total cholesterol level below 200 mg/dL does not increase the risk for stroke.
C. "My risk for a stroke increases if my HbA1c level is 6 percent or less."
D. "Having a total cholesterol level below 200 mg/dL increases my risk for a stroke."