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 {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A,B,C"},"D":{"answers":"A"},"E":{"answers":"B"}}
Explanation
Hypercapnia: Malignant Hyperthermia
Malignant hyperthermia (MH) is a life-threatening reaction to anesthesia, causing uncontrolled muscle metabolism and CO₂ buildup.
Wheezes: Latex Allergy
A latex allergy can trigger anaphylaxis, leading to airway swelling and bronchospasm, which cause wheezing.
Tachycardia: Malignant Hyperthermia, Latex Allergy, Hypovolemic Shock
Tachycardia is a common response to stress, hypoxia, allergic reactions, or shock.
MH: Increased metabolism causes hyperthermia and tachycardia.
Latex Allergy: Anaphylaxis can cause vasodilation and compensatory tachycardia.
Hypovolemic Shock: The body compensates for low blood volume by increasing heart rate.
Muscle Rigidity: Malignant Hyperthermia
A hallmark sign of MH is generalized muscle rigidity, especially in the jaw and chest, due to sustained muscle contractions.
Urticaria: Latex Allergy
Latex allergy causes histamine release, leading to itching, rash, and hives (urticaria).
Correct Answer is A
Explanation
A. APs can remind clients to use the incentive spirometer as part of their role in promoting basic care and client independence.
B. Observing the position of the suspended weight is a nursing responsibility because improper traction can lead to complications.
C. Asking the client to describe their pain requires assessment, which is outside the scope of an AP’s role.
D. Checking the pedal pulse is an assessment task that requires nursing judgment and should not be delegated to an AP.
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