Difficulty: Medium
Average Score: 85%
Simulated
The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients on a medical unit. Which information provided by the UAP warrants immediate intervention by the nurse?
Correct answer
C
Rationale
Hypertension (198/102) with Procrit (C) suggests a serious side effect, requiring immediate intervention. Hemoptysis (A), tripod position (B), and stomach upset (D) are expected or less urgent.