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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

Explanation

A. The priority is to immediately intervene in the care being provided by the UAP and assess the client's condition to ensure prompt intervention if necessary.

B. While educating the UAP is important, immediate assessment and intervention for the client take precedence.
C. Investigating the reason for the UAP's actions can wait until after the client's condition has been assessed and stabilized.
D. Administering oral medications can wait until after the client's condition has been assessed and stabilized.

A. The client's need for pain medication should be determined. B. The nurse manager should be updated on the client's status. C. The client's status should be conveyed to the chaplain. D. The impending signs of death should be documented.

Correct Answer is A

Explanation

A. Ensuring comfort during the dying process is paramount in end-of-life care. Assessing and managing pain promptly supports quality of life and dignity in the client's final moments.
B. The nurse manager should be updated on the client's status. While communication with the nurse manager is important, it is not the immediate priority when a client is experiencing discomfort or pain.
C. The client's status should be conveyed to the chaplain. Involving spiritual care is important but secondary to addressing any immediate physical comfort needs of the client.
D. The impending signs of death should be documented. Documentation is important, but it is a secondary priority to the direct care and comfort needs of the client.

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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

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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Patient Data

Exhibits

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