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 D
Explanation
D. Restlessness can be an early sign of hypoxia. Chest wall movement provides information about the effort and effectiveness of breathing, and the color of the nails can indicate cyanosis, which is a sign of poor oxygenation. These data points are directly related to assessing respiratory status and the severity of pneumonia.
A. Hiccups, sweating, and blood pressure can provide useful information about the patient's condition, they do not directly indicate the severity of respiratory distress or oxygenation status. Hiccups can be a sign of diaphragmatic irritation, sweating can indicate fever or infection, and blood pressure is a general vital sign but not specific to respiratory function.
B. Capillary refill can provide information about peripheral perfusion, and the amount of sputum can be relevant to respiratory status, particularly in an infection like pneumonia. Trembling might indicate fever or anxiety but is less directly related to respiratory status compared to other signs.
C. Pupil size and sneezing are not directly related to respiratory function in pneumonia. Pain location could be relevant if it indicates pleuritic pain, but this set of data does not provide the most critical information for assessing respiratory function and oxygenation in a patient with pneumonia.
Correct Answer is ["A","B","C","D"]
Explanation
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.