A nurse is Caring for a tent in the emergency department
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
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)
Pulse rate 84/min
Blood pressure 106/76 mm Hg
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Obtain the client's vital signs: While vital signs are important after a seizure, they are not the priority during the event. The first action should focus on protecting the client from injury and ensuring their airway remains open.
B. Notify the rapid response team: Notifying the rapid response team is not the first step. The nurse should prioritize ensuring the client’s safety during the seizure, including turning them on their side to prevent aspiration or injury.
C. Perform a neurologic check: A neurologic check is important after the seizure has ended to assess for changes in mental status or neurological function. However, during the seizure, the immediate priority is to ensure the client’s safety and airway.
D. Turn the client on their side: This priority action during a tonic-clonic seizure helps maintain the airway, prevents aspiration, and allows any secretions to drain from the mouth. Ensuring safety during the seizure is crucial before performing other assessments.
Correct Answer is A
Explanation
Rationale:
A. Decontaminate hands with an alcohol-based hand rub after taking the client's pulse:
Alcohol-based hand rubs are effective for decontaminating hands after routine tasks like taking a pulse, provided hands are not visibly soiled. They are effective in removing most pathogens, making them ideal.
B. Dry hands by starting from the wrist and moving toward the fingers: Hands should be dried by patting them gently with a clean paper towel, starting from the fingers and moving toward the wrist. This technique reduces the risk of transferring pathogens to clean areas.
C. Wash hands with an alcohol-based hand rub if you have artificial nails: Alcohol-based hand rubs should not be used if artificial nails are present, as they may not effectively remove pathogens from under the nails. Handwashing with soap and water is preferred in these cases.
D. Lather hands with soap and apply friction under running water for 5 seconds: Handwashing should involve lathering with soap for at least 20 seconds, not 5, to ensure that friction is applied across all areas of the hands to remove pathogens effectively.
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