Questions 117

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Adult Health Med Surg NCLEX Test Bank Questions

Extract:

The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 1 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.


Question 1 of 5

Which of the following assessment findings from the triage note require immediate follow-up? Select all that apply.

Correct Answer: A,B,C,F,G

Rationale: Blood pressure (94/57) indicates hypotension, temperature (105°F) suggests hyperthermia, pulse (115) and respirations (26) indicate tachycardia and tachypnea, neurological findings (lethargy, confusion) suggest altered mental status, and thready pulses indicate poor perfusion—all requiring immediate follow-up. Pulse oximetry (95%) and clear lung sounds are stable.

Extract:


Question 2 of 5

Correct Answer:

Rationale:

Question 3 of 5

Correct Answer:

Rationale:

Question 4 of 5

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Rationale:

Question 5 of 5

Correct Answer:

Rationale:

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