The nurse is continuing to care for the client.

Exhibits

A nurse is evaluating the client's response to therapy. Which of the following recent findings indicate the client's condition has improved or not changed? For each assessment finding, click to specify if the finding indicates that the client's condition has improved or has not changed.

Heart rate

Blood pressure

Edema

Deep tendon reflexes

Answer and Explanation

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

Finding	Improved	Not changed
Heart rate		✓
Blood pressure	✓
Edema	✓
Deep tendon reflexes	✓

Rationale

Heart rate: Not changed
- The heart rate increased from 72/min to 90/min, indicating no improvement.
Blood pressure: Improved
- The blood pressure decreased from 166/110 mm Hg to 152/90 mm Hg, indicating improvement.
Edema: Improved
- The edema decreased from +3 pitting to +2 pitting, indicating improvement.
Deep tendon reflexes: Improved
- The patellar reflex decreased from 4+ to 2+, indicating improvement.

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Correct Answer is C

Explanation

A. Tympanic thermometers are not recommended for newborns because the ear canal is difficult to assess accurately in this age group.

B. Oral temperatures are not recommended for newborns due to the difficulty in ensuring accuracy.

C. The axillary site is the recommended method for obtaining a newborn's temperature. It is safe and non-invasive.

D. Rectal temperatures are accurate but are invasive and may cause discomfort or injury. It should only be used if other methods are not feasible.

A. "I will monitor the client's blood glucose level every 8 hours." B. "I will hang a new bag of TPN and IV tubing every 24 hours." C. "I will increase the rate of the TPN infusion to ensure the correct amount is given." D. "I will obtain the client's weight every other day."

Correct Answer is B

Explanation

A. "I will monitor the client’s blood glucose level every 8 hours": Incorrect. Blood glucose should be monitored more frequently, typically every 4-6 hours, due to the risk of hyperglycemia.

B. "I will hang a new bag of TPN and IV tubing every 24 hours": This practice reduces the risk of infection associated with TPN, which is a high-risk therapy.

C. "I will increase the rate of the TPN infusion to ensure the correct amount is given": Incorrect. The TPN infusion rate should not be adjusted without a provider's order, as it can cause hyperglycemia or fluid overload.

D. "I will obtain the client’s weight every other day": Incorrect. Daily weights are necessary to monitor fluid status and nutritional effectiveness.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is obtaining the temperature of a newborn. Which of the following sites should the nurse use?

Correct Answer is C

Explanation

A charge nurse is monitoring a newly licensed nurse who is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following statements by the newly licensed nurse indicates an understanding of the procedure?

Correct Answer is B

Explanation

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