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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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Free Nursing Study Resources

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

Explanation

Continuous pulse oximetry monitoring is indicated for assessing oxygen saturation and respiratory status, especially in a client with a history of chronic kidney disease and a previous septic episode. It helps monitor the client's respiratory function.

Calculation of intake and output is indicated to assess fluid balance, which is crucial in clients with chronic kidney disease and a history of acute kidney injury. It helps monitor fluid management.

Daily weights are indicated to monitor fluid retention and changes in the client's weight, which can be affected by the client's kidney condition and the administration of intravenous fluids.

IV 0.9% normal saline continuous infusion at 100 mL/hr is indicated to maintain hydration and promote renal function in clients with chronic kidney disease. It helps ensure adequate fluid balance.

IV potassium-sparing diuretics may be contraindicated because they can potentially affect electrolyte balance, and in some cases, they might not be suitable for clients with chronic kidney disease. The use of diuretics should be carefully evaluated and managed by the healthcare provider.

A. Edema B. Irritability C. Fatigue D. Dry skin E. Intense thirst F. Muscle weakness G. Hypertension

Correct Answer is ["A","D","E","F"]

Explanation

A. Edema can be a symptom to watch for, as it may indicate fluid retention or imbalance, especially in a client who has received intravenous fluids.

D. Dry skin may be a symptom to observe, as it could suggest dehydration or fluid imbalances.

E. Intense thirst is a symptom to be alert for, as it may be an indication of dehydration or an electrolyte imbalance.

F. Muscle weakness is a potential symptom to monitor for, as it could be related to electrolyte imbalances or other complications following surgery and injury.

B, C, and G are not the primary symptoms to expect based on the client's information and history, but they should still be monitored as part of routine assessment. Irritability and fatigue can be nonspecific symptoms that may occur in various clinical situations. Hypertension may or may not be a symptom, and it is essential to assess the client's blood pressure in the context of their overall condition.

The client's history and the presence of medical devices and surgical intervention indicate the need for close monitoring of fluid balance and electrolyte status.

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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 {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

Correct Answer is ["A","D","E","F"]

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.