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Exhibits

The nurse reviews the client’s medical record from admission to 1930 hrs. Click to indicate whether the assessment finding has improved or not changed.

A.

Dyspnea

B.

Heart rate

C.

Blood pressure

D.

Oxygen saturation

E.

Respiratory rate

F.

Oral intake

G.

Lung sounds

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"B"}}

Assessment Finding

Improved

No change

Dyspnea

 

✅

Heart rate

✅

 

Blood pressure

✅

 

Oxygen saturation

✅

 

Respiratory rate

✅

 

Oral intake

✅

 

Lung sounds

 

✅

Rationale:

Improved:

Heart rate and blood pressure are slightly improved by 1930, likely due to the medications (furosemide, enalapril) helping manage fluid retention and blood pressure.

Oral intake has improved, but monitoring of this is critical given the recent lack of eating for several days.

No change:

Dyspnea remains unchanged, since the adolescent is still dyspneic with activity.

Lung sounds remain unchanged, indicating that there may still be some wheezing or fluid buildup in the lungs.


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Related Questions

Correct Answer is D

Explanation

A. Hypertension is not a common side effect of desmopressin.

B. Hyperkalemia is not typically associated with desmopressin.

C. Hypoglycemia is not a common side effect of desmopressin, as it is not used to manage blood glucose levels.

D. Desmopressin can cause water retention, leading to dilutional hyponatremia, which is a critical side effect to monitor for in clients receiving the medication.

Correct Answer is B

Explanation

A. A weight of 14.5 kg (32 lb) is normal for a 3-year-old.

B. A respiratory rate of 45 breaths per minute is elevated for a 3-year-old, whose normal range is 20-30 breaths per minute.

C. A blood pressure of 90/50 mm Hg is normal for a toddler.

D. A heart rate of 110/min is within the expected range for a 3-year-old.

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