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Exhibits

The nurse is reviewing the client's medical record. Which of the following findings indicates the client's condition has improved? Select all that apply.

Echocardiogram results

Blood pressure

Urinary output

Pain level

Respiratory rate

Heart rate

Oxygenation saturation

Answer and Explanation

Correct Answer : B,D,E,F,G

Echocardiogram results would provide information about the structure and function of the heart, particularly regarding any changes in cardiac function or wall motion abnormalities that might have been detected during the acute phase. It does indicate signs of improvement.
B.   Blood pressure is an important vital sign that reflects cardiovascular status. In the context of acute coronary syndrome or myocardial infarction, a stable or improving blood pressure indicates adequate perfusion to vital organs, including the heart. A decrease in blood pressure from hypertensive levels seen earlier could indicate stabilization of the client's condition.
C.   Urinary output is a critical indicator of renal perfusion and function. During acute illness, including cardiac events, decreased urinary output can indicate poor perfusion due to decreased cardiac output or hypoperfusion. In this scenario the output is still inadequate.
D.   Pain level, specifically chest pain in the context of acute coronary syndrome, is a subjective indicator of the client's cardiac status. A reduction in pain intensity, as reported by the client, can indicate that the treatment, such as nitroglycerin for angina, is effective in relieving myocardial ischemia. Therefore, a decrease in pain level suggests improvement in the client's cardiac condition.
E.   Respiratory rate is another vital sign that reflects the client's respiratory effort and overall respiratory status. In the context of acute cardiac events, respiratory rate can increase due to pain, anxiety, or respiratory distress. A decrease in respiratory rate suggests improved respiratory comfort and potentially reduced cardiac workload, indicating improvement in the client's condition.
F.   Heart rate is a crucial vital sign that reflects cardiac workload and rhythm. In acute coronary syndrome, tachycardia is often present due to sympathetic stimulation and the body's response to myocardial ischemia. A decrease in heart rate suggests that the client's cardiac workload has decreased, possibly indicating improved myocardial perfusion and stability.
G.   Oxygen saturation reflects the amount of oxygen bound to hemoglobin in the blood, which is essential for tissue oxygenation. In acute cardiac events, hypoxemia can occur due to impaired cardiac function or respiratory compromise. Improvement in oxygen saturation indicates improved tissue oxygenation, possibly due to effective management of cardiac function or respiratory support.

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Correct Answer is C

Explanation

C. A bed alarm is a device that triggers an alert when the client attempts to get out of bed or leaves a designated area. Bed alarms can be effective in alerting nursing staff to the client's movements, allowing for timely intervention to prevent wandering and ensure the client's safety. This intervention is commonly used in healthcare settings to monitor clients at risk for falls or wandering.

A Moving the client to a double room may not necessarily prevent wandering. In fact, it could potentially increase the risk if the client wanders into another resident's space or attempts to leave the room altogether.

B. Using chemical restraints (such as medications to sedate or calm the client) is not recommended unless absolutely necessary for the safety of the client or others. It does not address the underlying cause of wandering and can have significant adverse effects on the client's health and well-being.

D. Providing excessive stimulation can overwhelm and agitate clients with dementia, potentially worsening behaviors such as wandering. It is important to offer activities that are calming, engaging, and appropriate for the client's cognitive abilities.

A. Elevation in blood pressure B. Adventitious breath sounds C. Respiratory rate of 24/min D. Weight loss of 1.8 kg (4 lb) in the past 24 hr

Correct Answer is D

Explanation

D. A weight loss of 1.8 kg (4 lb) in the past 24 hours indicates effective diuresis (urine output) and reduction in fluid volume, which is the therapeutic goal of furosemide in treating pulmonary edema.

A Furosemide is a loop diuretic that typically causes a decrease in blood pressure by promoting the excretion of excess fluid and sodium from the body.

B. Adventitious breath sounds such as crackles (rales) indicate the presence of fluid in the lungs, which is a characteristic finding in pulmonary edema.

C. A respiratory rate of 24 breaths per minute is within normal range for an adult at rest. While this respiratory rate is not abnormal, it also does not directly indicate whether furosemide is effective in treating pulmonary edema.

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Exhibits The nurse is reviewing the client's medical record. Which of the following findings indicates the client's condition has improved? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a medical-surgical unit is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?

Correct Answer is C

Explanation

A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective?

Correct Answer is D

Explanation

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Exhibits

The nurse is reviewing the client's medical record. Which of the following findings indicates the client's condition has improved? Select all that apply.