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 A
Explanation
A. Maintaining the client on NPO (nothing by mouth) status is essential in the management of acute pancreatitis. This helps to rest the pancreas and prevent stimulation of pancreatic enzyme production, which can worsen the condition.
B. Monitoring for hypercalcemia is not a primary focus in acute pancreatitis. Hypocalcemia, rather than hypercalcemia, is more commonly associated with pancreatitis due to the deposition of calcium in areas of fat necrosis.
C. Administering antihypertensive medications is not a priority in the initial management of acute pancreatitis unless the client is also experiencing hypertension. The focus should be on fluid management and preventing complications like infection and shock.
D. Placing the client in a supine position is not recommended for acute pancreatitis. The client should be positioned in a semi-Fowler's position to reduce abdominal pressure and promote comfort.
Correct Answer is D
Explanation
A. Clients in protective isolation require more frequent temperature monitoring due to their high risk for infection. Monitoring once every 6 hours may not be sufficient to detect early signs of infection.
B. An N95 respirator is necessary for airborne precautions (e.g., tuberculosis) but is not required for protective isolation unless indicated for another reason.
C. While disposable plates and utensils may be used, they are not a primary requirement for infection prevention in protective isolation. Properly cleaned and sanitized utensils are generally safe.
D. Protective isolation requires positive-pressure airflow to prevent airborne pathogens from entering the client’s room, reducing the risk of infection in immunocompromised individuals.
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