Patient Data

Exhibits
The healthcare provider has obtained the arterial blood gas and chest X-ray results. New prescriptions have been entered in the client's electronic health record.
Nursing Action: Indicated/ Contraindicated

IV 0.9% normal saline continuous infusion at 100

Daily weights

Calculation of intake and output

IV potassium sparing diuretic

Continuous pulse oximetry monitoring

Electrocardiogram monitoring

Answer and Explanation

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

A.   Given the client's chronic kidney disease and the risk of fluid overload, a high rate of normal saline infusion may not be appropriate without careful assessment and specific indication from the healthcare provider.
B.   Monitoring daily weight is essential in managing fluid balance and assessing for potential fluid overload, especially in a child with chronic kidney disease.

C.   Accurate measurement of intake and output is crucial in managing fluid balance and monitoring kidney function, particularly in a patient with a history of acute kidney injury and chronic kidney disease.
D.   The client already has an elevated potassium level, and administering a potassium-sparing diuretic could worsen hyperkalemia, leading to dangerous cardiac complications.
E.   Continuous monitoring of oxygen saturation is important due to the presence of bibasilar infiltrates on the chest X-ray, which could indicate a potential respiratory issue.
F.   ECG monitoring is indicated due to the elevated potassium level (5.3 mEq/L), which can cause cardiac arrhythmias. The irregular heart rate further supports the need for ECG monitoring.

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

Explanation

A. Oxygen saturation of 98% on room air indicates that the client is maintaining adequate oxygenation without the need for supplemental oxygen.
B. A urine output of 20 ml within the last one hour is insufficient and could indicate an acute kidney injury.
C. Presence of crackles indicates ongoing pulmonary involvement, which does not suggest stabilization.
D. A heart rate within the normal range for a 7-year-old child (70-120 beats/minute), showing improvement from the previously irregular and elevated rate.
E. Respiratory rate of 26 breaths/minute is now within the normal range for a child (20-30 breaths/minute), indicating improved respiratory function.
F. A blood pressure of 126/76 mm Hg is within the normal range for a child.

G. Tall T wave and widened QRS complex suggest hyperkalemia, which is a serious condition and does not indicate stabilization.
H. An oral temperature of 37.1 C Indicates that the fever has resolved, suggesting that the infection or inflammatory response is under control.

A. Chesty B. Start oxygen 3 L via nasal cannula C. Acetaminophen 350 mg PO q4h for temperature greater than 101 F (38.3") D. Normal saline 150 mi/hour E. NPO F. Start a IV G. Sputum culture H. Place the client on a cardiorespiratory monitor

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

Explanation

A. Not a priority compared to monitoring vital signs and ensuring adequate oxygenation.

B: Increased oxygen flow is necessary to manage the client's respiratory distress and history of smoking. Correct Answer: 3 L, not 1 L as initially listed.
C: Acetaminophen 350 mg PO q4h for temperature greater than 101 F (38.3°C): Important for fever management but not the first priority in acute respiratory distress.
D: Helps maintain hydration but is secondary to respiratory support in this scenario.

E: Not applicable as there is no immediate need for surgery or risk of aspiration currently indicated.
F: Important for medication administration and fluid balance but follows after ensuring respiratory function.
G: Useful for diagnosing the cause of respiratory symptoms but not a first-line action.

H: Essential for continuously assessing the client's respiratory and cardiac status due to difficulty breathing.

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Patient Data Exhibits The healthcare provider has obtained the arterial blood gas and chest X-ray results. New prescriptions have been entered in the client's electronic health record. Nursing Action: Indicated/ Contraindicated

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Which assessment findings indicate that the client has stabilized? Select all that apply.

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

Explanation

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

Explanation

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Patient Data

Exhibits
The healthcare provider has obtained the arterial blood gas and chest X-ray results. New prescriptions have been entered in the client's electronic health record.
Nursing Action: Indicated/ Contraindicated