The nurse is reviewing the patient's record. Select to highlight the findings that demonstrate that the patient is improving.
1430: Nurses' Note: Urine output 50 mL/hr dark amber color. Continues to be lethargic.
1430: Vital Signs: Temp 100.4°F (37.8°C) HR 110 bpm: regular RR 24 breaths/min: rapid, deep SpO2 98% on room air BP 94/56 mm Hg
1430: Labs: Glucose 460 mg/dl
HR 110 bpm
regular RR 24 breaths/min
BP 94/56 mm Hg
Glucose 460 mg/dl
The Correct Answer is ["A","B","C","D"]
HR: 110 bpm; regular - The heart rate has decreased from 115 bpm and is now regular, suggesting improved cardiac rhythm stability.
RR: 24 breaths/min; rapid, deep - The respiratory rate has decreased from 26 breaths/min, indicating less rapid breathing.
BP: 94/56 mm Hg - While the blood pressure remains relatively low, there is a slight improvement compared to the previous reading.
Glucose 460 mg/dl - The glucose level has decreased from 525 mg/dL and 530 mg/dL in previous readings. While still elevated, this indicates some improvement in hyperglycemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
B. Maintaining a healthy weight is important for managing a hiatal hernia. Excess body weight can increase abdominal pressure and exacerbate symptoms. Weight loss, if necessary, can help reduce the frequency and severity of symptoms.
C. Elevating the head of the bed helps prevent the reflux of stomach contents into the esophagus while sleeping. Gravity helps keep the stomach contents down, reducing the risk of acid reflux and associated symptoms.
D. Caffeine and spicy foods can irritate the stomach lining and exacerbate symptoms of hiatal hernia, such as heartburn and acid reflux. Reducing the intake of these foods can help manage symptoms.
A. This is not typically a recommendation for managing a hiatal hernia. Drinking fluids is important for overall health and digestion. However, it is advisable to avoid drinking large amounts of fluids quickly, especially with meals, as this can increase intra-abdominal pressure and worsen symptoms.
E. Lying down after meals can increase the risk of reflux and worsen symptoms of a hiatal hernia. It is generally recommended to remain upright for at least a couple of hours after eating to prevent reflux.
Correct Answer is C
Explanation
C. Medical nutrition therapy for diabetes involves creating a well-balanced, individualized meal plan that meets the patient's nutritional needs while helping to manage blood glucose levels. This approach can be healthy for the entire family and does not require separate meals or special foods. It promotes overall healthy eating habits that everyone can benefit from.
A. Low-carbohydrate diets may be considered for some patients but the emphasis of a diabetic diet is not necessarily on high-protein intake. Instead, the focus is on balanced meals that include appropriate amounts of carbohydrates, proteins, and fats.
B. People with diabetes do not require special foods; rather, they need to make healthier choices from the foods available. The emphasis is on a balanced diet that can include regular foods, with modifications to portion sizes and meal timing to manage blood glucose levels effectively.
D. It is not necessary to completely avoid sugars and fats; rather, the focus should be on moderating intake and choosing healthier options. For example, limiting added sugars and unhealthy fats (like trans fats and saturated fats) is important, but healthy fats (such as those from nuts, seeds, and avocados) can be part of a balanced diet.
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