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Exhibits

Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.

Electrocardiogram: Tall T wave and widened QRS complex

Blood pressure: 126/76 mm Hg

Basilar crackles

Urine output: 20 mL in the last hour

Respirations: 26 breaths/minute

Heart rate: 72 beats/minute

Oxygen saturation 98% on room air

A normal body temperature (98.9°F or 37.1°C orally).

Answer and Explanation

Correct Answer : B,F,G,H

A. An electrocardiogram with a tall T wave and widened QRS complex may indicate electrolyte imbalances or cardiac issues, which are not indicative of stabilization.

C. Basilar crackles can be a sign of pulmonary or cardiac issues and are not indicative of stabilization.

D. A urine output of 20 mL in the last hour may suggest reduced kidney function or hydration status and is not indicative of stabilization.

E. A respiratory rate of 26 breaths/minute may indicate respiratory distress and is not indicative of stabilization.

The assessment findings that suggest stabilization include:

A blood pressure within the normal range (126/76 mm Hg).

A heart rate within the normal range (72 beats/minute).

Oxygen saturation of 98% on room air, indicating adequate oxygenation.

A normal body temperature (98.9°F or 37.1°C orally).

These vital signs and clinical parameters are within normal ranges, suggesting that the client's condition is stable at this time.

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Correct Answer is ["B","F","H"]

Explanation

For this client with a history of Wilms tumor, a radical nephrectomy, chronic kidney disease, and ongoing follow-up by oncology and nephrology services, the nurse should prioritize the following three care needs:

B. Identifying cardiac arrhythmias: Given the history of chronic kidney disease and potential electrolyte imbalances, cardiac arrhythmias are a significant concern that should be assessed and monitored for.

F. Monitoring fluid status: Fluid balance is crucial in clients with chronic kidney disease, and monitoring for fluid overload or dehydration is essential. This is especially important because of the potential need for fluid restrictions.

H. Assessing for worsening respiratory status: Assessing respiratory status is important, as clients with chronic kidney disease may be at risk for respiratory complications, including fluid overload, pulmonary edema, or other issues that can impact their respiratory status.

The other options are not the top priorities based on the client's history and current condition:

A. Collaborating with a dietitian to prepare a low-protein diet is important but may not be the immediate priority.

C. Performing diagnostic testing to determine the cause of a fever is necessary, but it does not take precedence over the immediate concerns of cardiac arrhythmias, fluid status, and respiratory status.

D. Educating the client and family on the importance of fluid restrictions is important, but it is related to monitoring fluid status and may be part of ongoing care.

E. Administering antipyretic medication as needed is relevant for fever management but not a top priority until the cause of the fever is determined.

G. Reassessing vital signs is part of ongoing care but may not be the immediate priority over identifying cardiac arrhythmias and assessing for worsening respiratory status.

I. Investigating acid/base complications is important but may not be the immediate priority when cardiac, fluid, and respiratory status are concerns.

A. Normal gait is not fully expected. B. Growth and development will be delayed. C. Heredity influences the outcome of clubfoot. D. Correction will require serial casting

Correct Answer is D

Explanation

A. Normal gait can be expected with appropriate management and treatment for clubfoot. With early and effective intervention, many children with clubfoot can achieve a normal gait.

B. Growth and development are not typically delayed as a long-term outcome of clubfoot when it is appropriately managed. The goal of treatment is to achieve normal foot development and function.

C. While heredity can play a role in clubfoot, it is not typically a sole determinant of the outcome. The success of treatment primarily depends on the timeliness and effectiveness of the interventions.

D Correction will require serial casting.

Unilateral clubfoot is a congenital deformity of the foot that can often be effectively managed with non-surgical interventions. Serial casting is a common and successful approach used to gradually correct the deformity. Parents should be informed that serial casting is likely to be a part of the treatment plan for their child's clubfoot.

Therefore, it is essential to educate parents that correction of unilateral clubfoot will likely require serial casting and that with appropriate treatment, the child can achieve a normal gait and experience normal growth and development.

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Exhibits Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","F","H"]

Explanation

The nurse is caring for an infant with unilateral clubfoot. Which information should the nurse include in parent education about long-term outcomes?

Correct Answer is D

Explanation

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Exhibits Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.

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Exhibits

Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.