ATI PN Adult Medical Surgical 2020 with NGN
ATI PN Adult Medical Surgical 2020 with NGN ( 79 Questions)
Temperature change from 36.6° C (97.8° F) to 38.8° C (101.9° F) is a significant finding that indicates fever, which can be caused by infection, inflammation, or other conditions. However, this is not the priority finding because fever is usually a secondary response to an underlying problem and can be treated with antipyretics and fluids.
Heart rate change from 110/min to 68/min is a notable finding that indicates bradycardia, which can be caused by medication, vagal stimulation, hypothermia, or cardiac dysfunction. However, this is not the priority finding because bradycardia may not be symptomatic or life-threatening unless it is accompanied by hypotension, chest pain, or altered mental status.
Blood pressure change from 118/78 mm Hg to 86/50 mm Hg is the priority finding that indicates hypotension, which can be caused by blood loss, dehydration, shock, or medication. Hypotension can impair tissue perfusion and oxygenation and lead to organ failure and death if not corrected promptly. The nurse should assess the client for signs of shock, such as tachycardia, tachypnea, pallor, diaphoresis, or confusion, and initiate interventions to restore blood pressure and circulation.
Respiratory rate change from 12/min to 20/min is a minor finding that indicates tachypnea, which can be caused by anxiety, pain, fever, or respiratory distress. However, this is not the priority finding because tachypnea may be a compensatory mechanism to increase oxygen delivery or eliminate carbon dioxide and may not affect gas exchange or acid-base balance unless it is severe or prolonged.
Choice A reason: Temperature change from 36.6° C (97.8° F) to 38.8° C (101.9° F) is a significant finding that indicates fever, which can be caused by infection, inflammation, or other conditions. However, this is not the priority finding because fever is usually a secondary response to an underlying problem and can be treated with antipyretics and fluids.
Choice B reason: Heart rate change from 110/min to 68/min is a notable finding that indicates bradycardia, which can be caused by medication, vagal stimulation, hypothermia, or cardiac dysfunction. However, this is not the priority finding because bradycardia may not be symptomatic or life-threatening unless it is accompanied by hypotension, chest pain, or altered mental status.
Choice C reason: Blood pressure change from 118/78 mm Hg to 86/50 mm Hg is the priority finding that indicates hypotension, which can be caused by blood loss, dehydration, shock, or medication. Hypotension can impair tissue perfusion and oxygenation and lead to organ failure and death if not corrected promptly. The nurse should assess the client for signs of shock, such as tachycardia, tachypnea, pallor, diaphoresis, or confusion, and initiate interventions to restore blood pressure and circulation.
Choice D reason: Respiratory rate change from 12/min to 20/min is a minor finding that indicates tachypnea, which can be caused by anxiety, pain, fever, or respiratory distress. However, this is not the priority finding because tachypnea may be a compensatory mechanism to increase oxygen delivery or eliminate carbon dioxide and may not affect gas exchange or acid-base balance unless it is severe or prolonged.