Questions 118

NCLEX-RN

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Extract:

The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 6 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 two (2) findings in the nurses' note would require immediate follow-up and reported to the physician?

Correct Answer: B,C

Rationale: Generalized shivering may indicate worsening hypothermia or a cooling blanket complication, and low urine output suggests renal hypoperfusion or acute kidney injury, both requiring immediate physician notification. Temperature (
A), pulses (
D), and thirst (E) are expected or less urgent.

Extract:


Question 2 of 5

Correct Answer:

Rationale:

Question 3 of 5

Correct Answer:

Rationale:

Question 4 of 5

Correct Answer:

Rationale:

Question 5 of 5

Correct Answer:

Rationale:

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