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An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 42/min, respiratory rate 14/min, and BP 98/77 mm Hg. Which vital sign should the nurse re-measure?

A.

Temperature

B.

Respirations

C.

Blood pressure

D.

Heart rate

Answer and Explanation

The Correct Answer is D

A. The tympanic temperature of 37.1° C (98.8° F) is within normal limits and does not require re-measurement.  

 

B. The respiratory rate of 14/min is also within the normal range (12-20 breaths per minute).  

 

C. The blood pressure of 98/77 mm Hg is not alarmingly low and does not require immediate re-measurement.  

 

D. A pulse rate of 42/min indicates bradycardia (normal resting heart rate is typically between


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Correct Answer is C

Explanation

A. Metabolic alkalosis is characterized by a high pH and elevated bicarbonate levels, which is not present in these results.

B. Respiratory alkalosis would present with an increased pH and decreased PaCO2, which does not apply here.

C. The low pH (7.12) indicates acidemia, and the elevated PaCO2 (90 mm Hg) suggests hypoventilation and respiratory acidosis due to CO2 retention. The bicarbonate level is within normal limits, further supporting respiratory acidosis.

D. Metabolic acidosis would be indicated by a low pH and low bicarbonate levels; however, the bicarbonate is normal in this case, ruling out metabolic acidosis.

Correct Answer is D

Explanation

A. Nodules, specifically rheumatoid nodules, can occur in RA, but they are not typically an early manifestation.

B. Fremitus is related to lung assessment and is not a manifestation of rheumatoid arthritis.

C. Tenderness in the soles of the feet is not a classic early manifestation of RA.

D. Joint swelling is one of the hallmark early signs of rheumatoid arthritis due to inflammation of the synovial membranes.

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