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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 A

Explanation

A. The nurse should notify the charge nurse of the situation to ensure that the client’s legal rights, autonomy, and best interests are considered in making decisions regarding treatment.

B. Offering an antiemetic is not the primary concern when the client is refusing treatment; the issue is the refusal of care.

C. Administering a sedative without addressing the underlying issue would not be appropriate and could violate the adolescent’s autonomy.

D. Starting the IV per the parent's request without the adolescent’s consent may violate the adolescent’s rights and should not be done without careful consideration of legal and ethical principles.

Correct Answer is D

Explanation

A. Polyuria is more commonly seen in hyperglycemia, not hypoglycemia, so it is unlikely to be present with a blood glucose level of 55 mg/dL.

B. Dry, flushed skin is typically a sign of hyperglycemia (e.g., in diabetic ketoacidosis), not hypoglycemia.

C. Deep, rapid respirations are a symptom of metabolic acidosis or severe hyperglycemia, not hypoglycemia.

D. Tachycardia is a common compensatory response to hypoglycemia, as the body tries to increase glucose delivery to tissues.

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