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 C
Explanation
Rationale:
A. "Make sure family members wear masks whenever they are in the same room as you."
Masks are mainly recommended for the client with tuberculosis, not family members unless they are at high risk. The focus should be on good hygiene and cough etiquette.
B. "Return to work after two consecutive sputum cultures are negative." While negative sputum cultures are important, returning to work depends on completing the full treatment regimen and clinical improvement. Full treatment is essential for transmission control.
C. "Before coughing or sneezing, cover your mouth and nose with a tissue." This is the correct advice to prevent the spread of tuberculosis. Covering the mouth and nose with a tissue when coughing or sneezing helps contain respiratory droplets and protect others.
D. "Wear a high-filtration mask at home when family members are nearby." Wearing a high-filtration mask is generally necessary for healthcare settings. At home, focus should be on cough etiquette, good ventilation, and completing prescribed treatment.
Correct Answer is B
Explanation
Rationale:
A. "This finding may indicate possible medication toxicity." The red-orange color of the saliva is not indicative of toxicity but is a known, harmless side effect of rifampin. The nurse should reassure the client that this color change is common and not a sign of toxicity.
B. "This is an expected adverse effect of this medication." Rifampin can cause body fluids, including saliva, urine, and sweat, to turn a red-orange color. This is a well-known, expected adverse effect of the medication and does not require discontinuation or interventions.
C. "You will need to increase your fluid intake to resolve this problem." Increasing fluid intake will not affect the color change in body fluids caused by rifampin. The change in color is a benign side effect, and fluid intake does not resolve this issue.
D. "Your provider will prescribe a different medication regimen." The red-orange discoloration is a common side effect of rifampin and is not harmful. There is no need to change the medication regimen unless the client experiences other more serious side effects.
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