A nurse is caring for a client in the emergency department.
Click to highlight the findings that indicate that the client's condition is improving. To deselect a finding, click on the finding again.
Nurses notes:
1400:
Client admitted to the medical-surgical unit at 1200 today. Alert and orientated x4, heart and lung sounds clear. Client urinating 100 mL/hour. Client is tolerating soft diet and oral fluids. Bowel sounds are hyperactive in all 4 quadrants. Bilateral pedal pulses 2+. Blood glucose 310 mg/dL (74 to 106 mg/dL)
Vital signs:
1400:
Temperature 36.8° C (98.2 F)
Pulse rate 84/min
Respiratory rate 16/min
Blood pressure 106/76 mm Hg
Oxygen saturation 96% on room air
Alert and orientated x4, heart and lung sounds clear
Client is tolerating soft diet and oral fluids
Temperature 36.8° C (98.2 F)
The Correct Answer is ["A","B"]
Rationale
Client is alert and oriented x4, heart and lung sounds clear.
This shows that the client is stable and no longer experiencing confusion or respiratory distress, which are signs of improvement.
Client is tolerating soft diet and oral fluids.
The ability to tolerate food and fluids is a sign of recovery and better overall condition
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A decrease in blood pressure is the correct finding that indicates telmisartan has been effective. Telmisartan is an angiotensin II receptor blocker (ARB) used primarily to treat hypertension, and its effectiveness is typically measured by a reduction in blood pressure.
B. A respiratory rate of 16/min is within the normal range for adults and does not indicate the effectiveness of telmisartan, as the medication primarily affects blood pressure and not respiratory function.
C. A blood glucose of 110 mg/dL is within the normal range and does not directly reflect the effectiveness of telmisartan. While ARBs like telmisartan may have some effect on glucose metabolism, blood glucose levels are not the primary indicator of its effectiveness.
D. An increase in urinary output is not directly related to the effectiveness of telmisartan. While ARBs can have some mild diuretic effects, the primary expected outcome is a reduction in blood pressure, not an increase in urine output.
Correct Answer is C
Explanation
A. Diphenhydramine is an antihistamine and is primarily used for allergy symptoms or as a sedative. While it has anti-nausea properties, it is not the most effective medication for chemotherapy-induced nausea and vomiting.
B. Sertraline is an SSRI used primarily for depression and anxiety. It is not typically used for chemotherapy-induced nausea and vomiting.
C. Ondansetron is the most appropriate medication. It is a serotonin 5-HT3 receptor antagonist commonly used to prevent nausea and vomiting caused by chemotherapy. It works by blocking serotonin receptors in the gastrointestinal tract and central nervous system, preventing nausea.
D. Methylprednisolone is a corticosteroid and may be used as part of a combination regimen to manage nausea and vomiting associated with chemotherapy, but it is not the first-line medication for nausea. Ondansetron would typically be given first.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.