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. Sucralfate should be taken on an empty stomach, typically 1 hour before meals. This timing allows the medication to coat the ulcer site effectively and protect it from the acidic environment of the stomach, which increases after eating.
A. Taking sucralfate with an antacid can interfere with its action. Sucralfate works by forming a protective barrier on the ulcer site, and antacids can prevent sucralfate from binding properly to the ulcer. It's generally recommended to take sucralfate at least 30 minutes before or after antacids.
B. Sucralfate is not taken on an "as needed" basis for pain relief. It is prescribed as a regular, scheduled medication to provide continuous protection of the ulcer site. Pain relief from peptic ulcers comes as the ulcer heals, which sucralfate aids by protecting the mucosal lining.
C. Sucralfate does not need to be stored in the refrigerator. It should be stored at room temperature, away from moisture and heat, according to standard storage guidelines for most medications.
Correct Answer is B
Explanation
B. Expiratory wheezes are high-pitched, musical sounds produced by air passing through narrowed or obstructed airways. Wheezing is a hallmark sign of asthma, particularly during an exacerbation, and is usually more pronounced during expiration due to the increased effort required to expel air through the narrowed airways.
A. A pleural friction rub is a grating sound produced by the movement of inflamed pleural surfaces rubbing together. It is typically heard in conditions such as pleuritis (inflammation of the pleura) or pleurisy. This sound is not commonly associated with asthma exacerbations.
C. Rhonchi are low-pitched, snoring-like sounds that occur due to the presence of mucus or other secretions in the larger airways. While rhonchi can be heard in conditions with increased mucus production, such as bronchitis, they are not typically the primary sound associated with asthma exacerbations.
D. Fine rales, also known as crackles, are high-pitched, popping sounds heard during inspiration. They are usually associated with conditions involving fluid in the alveoli, such as pulmonary edema or interstitial lung disease. Crackles are not characteristic of asthma.
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