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Patient Data

Exhibits

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

Oxygen saturation 98% on room air

Urine output 20 mL in the last hour

Basilar crackles

Heart rate 72 beats/minute

Respiratory rate 26 breaths/minute

Blood pressure 126/76 mm Hg

Electrocardiogram Tall T wave and widened QRS complex

Temperature 98.9° F (37.1° C) orally

Answer and Explanation

Correct Answer : A,D,E,F,H

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.

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Correct Answer is ["A","C","D"]

Explanation

A. Contact precautions are essential to prevent the spread of MRSA to other patients and healthcare workers. This includes wearing gloves and gowns when entering the patient's room.

B. A low bacteria diet is not specifically relevant to managing MRSA and is more applicable to neutropenic patients.
C. Monitoring the white blood cell count helps in assessing the client's response to infection and identifying any potential systemic involvement.
D. Sending wound drainage for culture and sensitivity is crucial for identifying the specific strain of MRSA and determining the most effective antibiotic treatment.
E. Standard precautions are always necessary, but a mask is not required unless there is a risk of splashing or the patient has a respiratory infection.

A. Length of time of the exposure to tuberculosis. B. Current diagnosis of hepatitis B. C. History of intravenous drug abuse. D. Conversion of the client's purified protein derivative (PPD) skin test from negative to positive.

Correct Answer is B

Explanation

A. While the length of exposure can be relevant, it is not the most critical factor before starting isoniazid.
B. Isoniazid can cause hepatotoxicity, so a current diagnosis of hepatitis B is crucial to note as it increases the risk of liver damage.
C. A history of intravenous drug abuse is important for overall health assessment but is less critical than current liver disease.
D. Conversion of the PPD test indicates TB exposure, but assessing liver function and potential for hepatotoxicity is more urgent before starting the medication.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). What nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?

Correct Answer is B

Explanation

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Exhibits Nursing actions: Indicated/contraindicated/non-urgent

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Patient Data

Exhibits

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