The nurse reviews the entries in the medical record.
Click to highlight the findings that indicate improvement in the client's condition. To deselect a finding, click on the finding again.
Laboratory Results
1800:
WBC count 6,700/mm3 (5,000 to 10,000/mm3)
Hemoglobin 12 g/dL (14 to 18 g/dL)
Hematocrit 36% (40% to 52%)
Vital Signs
1800:
Blood pressure 112/74 mm Hg
Heart rate 95/min
Respiratory rate 18/min
Temperature 37.5° C (99.5° F)
Oxygen saturation 100% via 2 L/min nasal cannula
Assessment
1800:
Physical Exam:
General: no distress
HEENT: oropharynx clear, mucous membranes moist and pink
Respiratory: bilateral breath sounds clear
Gl: epigastric tenderness to palpation, no rebound tenderness or guarding
Neuro: awake and alert
WBC count 6,700/mm3 (5,000 to 10,000/mm3)
Hemoglobin 12 g/dL (14 to 18 g/dL)
Hematocrit 36% (40% to 52%)
Blood pressure 112/74 mm Hg
Heart rate 95/min
Respiratory rate 18/min
Temperature 37.5° C (99.5° F)
Oxygen saturation 100% via 2 L/min nasal cannula
no distress
mucous membranes moist and pink
no rebound tenderness or guarding
The Correct Answer is ["B","D","E","H","I","J","K"]
Blood Pressure: 112/74 mmHg (Previously 76/45 mmHg): The client's blood pressure has stabilized, suggesting improved circulatory volume and perfusion.
Heart Rate: 95/min (Previously 121/min): A decrease in heart rate indicates improved hemodynamic stability and a reduced compensatory response to blood loss.
Hemoglobin: 12 g/dL (Previously likely lower due to GI bleeding): Hemoglobin has improved, indicating successful correction of anemia, possibly due to blood transfusion.
Mucous Membranes: Moist and Pink (Previously Pale): Improved mucosal color and hydration suggest better oxygenation and volume status.
General Assessment: No Distress (Previously Diaphoretic, Uncomfortable): The client no longer shows signs of discomfort or distress, indicating symptom relief and better overall condition.
Oxygen Saturation: 100% on 2 L/min Nasal Cannula (Previously 98% on Room air): The client is maintaining adequate oxygenation with minimal supplemental oxygen.
Epigastric Tenderness Without Guarding or Rebound Tenderness: No worsening of GI symptoms suggests that the treatment plan (transfusion, IV fluids, and PPI therapy) is effective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Administering an antiemetic may help with nausea but does not address the cause of vomiting in this situation.
B. Vomiting in a client with an NG tube on suction suggests that the tube may be clogged or malfunctioning, leading to inadequate gastric decompression. The nurse should first check the function of the suction device and ensure the NG tube is patent.
C. Replacing the NG tube is not the first action. The nurse should first assess and troubleshoot before considering replacement.
D. Providing oral hygiene is important but not the priority when the client is actively vomiting.
Correct Answer is A
Explanation
A. Correct – Infants with heart failure experience fatigue during feeding, leading to poor weight gain. Limiting feeding time reduces energy expenditure.
B. Incorrect – Oxygen saturation should be checked more frequently than every 6 hours, especially if the infant has cyanosis or respiratory distress.
C. Incorrect – Daily weight monitoring is necessary to assess fluid status and nutritional intake.
D. Incorrect – The infant should be placed on their back for naps to prevent sudden infant death syndrome (SIDS).
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