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A nurse is Caring for a tent in the emergency department


Exhibits

Click to highlight the findings that indicate that the tents Condition is Improving. To deselect a finding, click on the finding again.

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)


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
     

A.

Client urinating 100 mL/hour.

B.

Client is tolerating soft diet and oral fluids.

C.

Bowel sounds are hyperactive in all 4 quadrants.

D.

Bilateral pedal pulses 2+.

E.

Blood glucose 310 mg/dL (74 to 106 mg/dL)

F.

Pulse rate 84/min

G.

Blood pressure 106/76 mm Hg

Answer and Explanation

The Correct Answer is ["A","B","D","E","F","G"]

Rationale for correct findings:

  • Client is urinating 100 mL/hour: This indicates improved kidney perfusion and rehydration. At 0900, the client reported frequent urination, which was likely osmotic diuresis leading to dehydration. A consistent urine output of 100 mL/hour suggests effective fluid resuscitation and that the kidneys are now functioning more optimally.
  • Client is tolerating soft diet and oral fluids:  The ability to tolerate a soft diet and oral fluids suggests that the client is recovering from nausea and dehydration. This is an important indicator of improvement in gastrointestinal function and overall metabolic status.
  • Pulse rate decreased to 84/min: The pulse rate has decreased from 110/min to 84/min, indicating that the client’s cardiovascular status is improving, likely due to improved hydration and metabolic control.
  • Blood pressure increased to 106/76 mm Hg: The client’s blood pressure has improved from 96/65 mm Hg to 106/76 mm Hg, reflecting a more stable circulatory volume and better perfusion. This improvement suggests that fluid resuscitation is helping to stabilize the client’s hemodynamic status.
  • Blood glucose decreased to 310 mg/dL: A decrease in blood glucose from 468 mg/dL to 310 mg/dL shows that insulin therapy is having a positive effect on reducing hyperglycemia. The blood glucose level is still high but moving in the right direction, indicating recovery from the acute phase of hyperglycemia.

Rationale for Incorrect Finding:

  • Bowel sounds are hyperactive in all 4 quadrants: Hyperactive bowel sounds remain unchanged from the initial assessment. It is not a sign of improvement, and could be related to the stress response, medications, or ongoing issues with the gastrointestinal system.


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Related Questions

Correct Answer is B

Explanation

Rationale:

A. "Wash your feet twice per day with antibacterial soap and hot water." Washing the feet twice a day with hot water can lead to skin damage and dryness, especially for clients with diabetes. It's important to use lukewarm water and mild soap to avoid irritation.

B. "Wear cotton rather than nylon socks." Cotton socks are recommended because they allow the feet to breathe and help absorb moisture, reducing the risk of fungal infections and promoting better circulation, which is important for clients with diabetes.

C. "Use a heating pad to keep your feet warm at night." Using a heating pad is not advisable for clients with diabetes, as they may have decreased sensation in their feet. This could result in burns or injury without the client noticing it.

D. "Wear loose-fitting slippers around the house." While it is important to wear comfortable footwear, loose-fitting slippers can increase the risk of tripping or injury. The client should wear well-fitted, supportive shoes to protect their feet.

Correct Answer is D

Explanation

Rationale:

A. "I am sure you will be able to still spend time with your grandchildren." While reassurance is important, this statement may not be realistic, and it does not acknowledge the client’s feelings of uncertainty. The client may need more support and guidance regarding their post-surgery recovery and limitations.

B. "Why do you think you won't be able to play with your grandchildren?" This question may sound confrontational or dismissive of the client’s concerns. It is more important to validate the client’s emotions and explore their feelings in a non-judgmental way..

C. "You will not be as active for a couple of years." This statement is overly negative and does not provide an opportunity to explore the client’s emotional needs. Recovery from knee arthroplasty varies and focusing on long-term inactivity could discourage the client.

D. "What are some of the activities you like to do with your grandchildren?" This open-ended question validates the client’s feelings and helps shift the focus towards their interests and goals. It allows the nurse to explore realistic expectations and discuss ways to resume activities after recovery, fostering a positive outlook.

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