A 38-year-old patient's vital signs at 8 a.m. are axillary temperature 99.6°F (37.6°C); pulse rate 88; respiratory rate 30. Which findings should be reported?

Correct Answer: D

Rationale: The axillary temperature of 99.6°F (37.6°C) is mildly elevated, as normal axillary temperature typically ranges from 97.6°F (36.4°C) to 98.1°F (36.7°C). While this alone may not always warrant immediate reporting, it becomes significant when paired with other abnormal findings. The respiratory rate of 30 breaths per minute is notably high, as the normal range for adults is 12–20 breaths per minute. Tachypnea (elevated respiratory rate) often indicates respiratory distress, infection, or metabolic disturbances, making it a critical finding that must be reported. The pulse rate of 88 falls within the normal range (60–100 beats per minute) and does not raise immediate concern. **Why D is correct:** Both the elevated temperature and the significantly increased respiratory rate are abnormal and clinically significant. Together, they suggest a potential underlying condition such as infection, sepsis, or respiratory compromise, necessitating prompt evaluation. Reporting these findings ensures timely intervention. **Why A is incorrect:** While the respiratory rate is abnormal and should be reported, ignoring the elevated temperature overlooks a key piece of clinical data. Fever can indicate infection or inflammation, and when combined with tachypnea, it strengthens the case for further assessment. **Why B is incorrect:** Reporting the temperature alone neglects the more urgent finding of tachypnea. A mildly elevated temperature without other symptoms may not always require immediate action, but the respiratory rate of 30 is a red flag that demands attention. **Why C is incorrect:** The pulse rate is normal and does not require reporting. While the temperature is slightly elevated, it is less concerning without additional abnormal findings. Pairing it with the normal pulse rate does not provide enough clinical significance to prioritize reporting over the respiratory rate. The combination of temperature and respiratory rate provides a clearer picture of potential physiological stress or pathology, making D the most appropriate choice for reporting. Ignoring either of these findings could delay diagnosis and treatment of a potentially serious condition.

Correct Answer: D

Rationale: Palpating the midclavicular line is the correct technique for assessing the apical pulse. The apical pulse is located at the point of maximal impulse (PMI), which is typically at the fifth intercostal space at the midclavicular line. This technique allows healthcare providers to accurately assess the heart rate and rhythm by listening to the heart sounds directly at this point.

Correct Answer: C

Rationale: The absence of the pedal pulse may not be significant if the patient has poor peripheral circulation or if the healthcare provider is focused on other pulse points. The pedal pulse is often weaker and may not always be palpable due to various factors, making its absence less concerning in certain situations. However, the absence of other pulses like radial or femoral pulses may indicate more critical conditions and require immediate attention.

Correct Answer: B

Rationale: The correct answer is B. An elderly patient who is incontinent, bedridden, and suffering from a serious illness like gastric cancer is at the highest risk for developing pressure ulcers. Being bedridden and incontinent increases the pressure on certain areas of the body, leading to tissue damage and the development of pressure ulcers. Additionally, the patient's age and underlying health condition further contribute to their risk. It is crucial to identify and address such risk factors promptly to prevent the occurrence of pressure ulcers in vulnerable patients.

Correct Answer: D

Rationale: Chest physiotherapy is the most effective intervention in cases of impaired gas exchange related to increased secretions. This technique helps mobilize and clear secretions from the airways, thereby improving gas exchange in the lungs. Placing a humidifier or administering oxygen by high humidity face mask may provide moisture but may not directly address the clearance of secretions. Encouraging increased fluid intake can help with hydration but may not address the underlying issue of impaired gas exchange due to secretions.