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A nurse is assisting with the care of a client.

Exhibits
For each finding at 1100, click to specify if the finding indicates that the client's condition has improved, worsened, or is unchanged.

A.

Temperature

B.

Pulse oximetry

C.

Respiratory rate

D.

Blood pressure

E.

Mucous membrane color

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}

Finding

Assessment

Rationale

Temperature: 38.6°C

Worsened

The temperature increased from 38.2°C to 38.6°C, suggesting worsening fever or infection.

Pulse oximetry: 95% on 40% O₂

Improved

The client’s oxygen saturation increased from 85% to 95%, though with supplemental O₂, showing improved oxygenation.

Respiratory rate: 22/min

Improved

RR decreased from 32 to 22, indicating better respiratory effort and less distress.

Blood pressure: 112/54 mmHg

Unchanged

Minimal change from 114/56 to 112/54; both readings are within similar ranges.

Mucous membrane color: pink

Improved

Pink mucous membranes indicate improved oxygenation and perfusion, compared to pale earlier.


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Related Questions

Correct Answer is D

Explanation

A. "When taking multiple temperatures, the sites should be rotated.":
This does not address the mother’s concern about the specific temperature reading and its significance.

B. "Because of her age, it is probably a bacterial infection.":
A temp of 100.4°F is low-grade and not diagnostic of bacterial infection, especially in an infant without other symptoms.

C. "Children usually run lower rather than higher temperatures when ill.":
Children often run higher fevers when ill, not lower.

D. "Rectal temperature readings are higher than temperature obtained orally.":
Rectal temperatures are typically 0.5°F to 1°F higher than oral readings. A rectal temp of 100.4°F is considered the threshold for fever in infants but may still be within normal for a well-appearing child.

Correct Answer is A

Explanation

A. Cover the wound with a sterile normal saline soaked dressing:
This keeps the exposed organs moist and reduces infection risk until surgical intervention.

B. Apply an abdominal binder to the wound area:
This can increase pressure and cause further damage to exposed organs.

C. Assure the client that this is an expected occurrence after surgery:
Evisceration is a surgical emergency, not expected.

D. Turn the client onto her side:
The client should be placed in a low Fowler’s position with knees bent to reduce abdominal strain-not on the side.

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