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
Explanation
B. Orange juice is highly acidic and can irritate the esophagus, leading to increased heartburn symptoms. Regular consumption of acidic beverages like orange juice can exacerbate GERD symptoms, making this a likely contributing factor to the client's heartburn.
A. Consuming low-fat meats is generally not a contributing factor to heartburn. Low-fat meats are less likely to cause reflux compared to high-fat foods, which can relax the lower esophageal sphincter and increase the risk of acid reflux.
C. Eating dinner early in the evening is generally recommended for managing GERD. This practice allows more time for the stomach to empty before lying down to sleep, reducing the likelihood of acid reflux during the night.
D. Sleeping on a large wedge-style pillow is also generally recommended for managing GERD. Elevating the head and upper body during sleep can help prevent acid from flowing back into the esophagus.
Correct Answer is A, B, C, D, E
Explanation
A. Shake the canister 3 to 5 seconds vigorously.
Before each use, it's important to shake the MDI to ensure proper mixing of the medication.
B. Place her lips firmly around the mouthpiece.
Creating a tight seal around the mouthpiece ensures that the medication is delivered directly into the airways.
C. Inhale slowly over 3 to 5 seconds while pushing down on the canister.
While pressing down on the canister, the client should inhale slowly to allow the medication to reach the lungs.
D. Hold her breath for 10 seconds.
After inhaling the medication, holding the breath for 10 seconds allows for better absorption of the medication into the lungs.
E. Exhale slowly through pursed lips.
After holding the breath, exhaling slowly through pursed lips helps to fully exhale and ensures that the medication remains in the airways.
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