Question 60 - Coordinated Care Practice Test for the NCLEX-PN Exam

Use the case study information provided to answer this question.

Which two of these parameters should the nurse monitor?

A. blood pressure
B. urinary output
C. neurologic status
D. temperature
E. blood glucose

Intro to Case

The nurse in the emergency department is caring for an 85-year-old female client who is accompanied by her adult son. The son noticed the client has grown progressively confused over the last few days and states, “Mom is just not acting right.” The son states the client is normally “totally with it.” The client fell this morning while trying to make coffee and has a black eye.

Nurse’s Notes

1100: Nurse called to client’s room. Client states, “my sister is coming home from school soon and I have to meet her at the bus stop.” Nurse reoriented client to place and time.

1130: Client’s son called nurse to bedside. Client had an episode of incontinence and saturated the bed sheets with urine. Changed client’s bed sheet and put an adult diaper on client.

1145: Peripheral venous access device (VAD) inserted in client’s right arm and Sodium Chloride 0.9% bolus started at 999 ml/hr per MD order.

History and Physical

Body System Findings
Neurological History of TIA x 3 within the last year
Genitourinary History of frequent UTIs, currently incontinent
of urine
Cardiovascular History of uncontrolled hypertension and
congestive heart failure
Endocrine History of diabetes mellitus type 2

Vital Signs

  1100
T 100.5°F
RR 20
BP 102/56
HR 98
SpO2 94%
Previous

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