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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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Free Nursing Study Resources

Correct Answer is B

Explanation

B. Providing the client with a trapeze bar allows them to move and reposition in bed independently without compromising the traction on the affected leg.

A Checking pressure points every 2 hours is generally recommended for clients at risk of developing pressure ulcers, but it's not specific to skeletal traction care.

C. Removing the weights prematurely can lead to loss of traction and compromise the therapeutic benefit of the traction.

D. When a client has skeletal traction, they should avoid using the affected limb for any weight-bearing activities or for repositioning

A. Severe pain at the site B. Blistering at the site C. Epithelialization at the site D. Edema at the site

Correct Answer is D

Explanation

D. Edema is expected in the initial hours and days following major burns and can be particularly pronounced in full-thickness burns due to extensive tissue damage and inflammation.

A Initially, full-thickness burns may not be as painful due to nerve damage; however, surrounding areas with partial-thickness burns or areas where nerve endings are intact can be extremely painful. The absence of severe pain at the site of full-thickness burns is common initially due to nerve damage, but pain management is crucial as inflammation progresses.

B. Full-thickness burns typically involve destruction of the entire epidermis and dermis, leading to the absence of blisters. Blisters are characteristic of partial-thickness burns, where the epidermis is partially damaged but not completely destroyed.

C. Epithelialization refers to the process of new skin cells migrating and covering the wound, a process that occurs during the later stages of wound healing. In the acute phase of full-thickness burns, epithelialization does not occur because the skin layers are completely destroyed. This process starts later once the wound has been adequately debrided and begins to heal.

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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 is caring for a client who has skeletal traction applied to the left leg. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is assessing a client who sustained major full-thickness burns to their lower legs 12 hr ago. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

Exhibits Which of the following 3 provider prescriptions does the nurse anticipate?

A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take?

A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider?

A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes. Which of the following statements by the client indicates effectiveness of the teaching?

A nurse is caring for a client who is postoperative and develops respiratory depression after receiving morphine for pain control. Which of the following medications should the nurse expect the provider to prescribe?

A charge nurse on a neurological unit is making room assignments for a group of clients. Which of the following clients should the nurse assign to the room closest to the nurses' station?

A nurse is providing teaching for a client who has diabetes mellitus about the self-administration of insulin. The client has prescriptions for regular and NPH insulins. Which of the following statements by the client indicates an understanding of the teaching?

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.