A nurse is caring for a client in the emergency department.
Click to highlight the findings that indicate that the client's condition is improving. To deselect a finding, click on the finding again.
Nurses notes:
1400:
Client admitted to the medical-surgical unit at 1200 today. Alert and orientated x4, heart and lung sounds clear. Client urinating 100 mL/hour. Client is tolerating soft diet and oral fluids. Bowel sounds are hyperactive in all 4 quadrants. Bilateral pedal pulses 2+. Blood glucose 310 mg/dL (74 to 106 mg/dL)
Vital signs:
1400:
Temperature 36.8° C (98.2 F)
Pulse rate 84/min
Respiratory rate 16/min
Blood pressure 106/76 mm Hg
Oxygen saturation 96% on room air
Alert and orientated x4, heart and lung sounds clear
Client is tolerating soft diet and oral fluids
Temperature 36.8° C (98.2 F)
The Correct Answer is ["A","B"]
Rationale
Client is alert and oriented x4, heart and lung sounds clear.
This shows that the client is stable and no longer experiencing confusion or respiratory distress, which are signs of improvement.
Client is tolerating soft diet and oral fluids.
The ability to tolerate food and fluids is a sign of recovery and better overall condition
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Pedal edema is more commonly associated with right-sided heart failure due to fluid retention in the lower extremities.
B. In left-sided heart failure, fluid backs up into the lungs, leading to pulmonary congestion and reduced renal perfusion. This can result in daytime oliguria (decreased urine output) as the kidneys receive less blood flow.
C. Neck vein distention is a hallmark of right-sided heart failure, not left-sided heart failure. It occurs due to increased venous pressure.
D. An enlarged liver is more commonly seen in right-sided heart failure due to congestion of the liver, but it is not a typical manifestation of left-sided heart failure.
Correct Answer is C
Explanation
A. Offering the dog water may not be appropriate unless the client requests it. The dog is working and may not need a break at that moment. Offering water without consulting the client could be intrusive.
B. Petting the dog is not appropriate unless the client specifically invites it. Service dogs are working animals and should not be distracted by strangers petting them.
C. Consulting the client before approaching the dog is the most respectful approach. Service dogs are vital to their handlers, and the nurse should always ask the client’s permission before interacting with the dog. This ensures that the handler's needs and the dog’s working status are respected.
D. Commanding the dog to sit is not appropriate unless directed by the client. The service dog is trained to respond to the client’s commands, and the nurse should not give commands to the dog unless the client asks for assistance.
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