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.
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) 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 urinating 100 mL/hour
Client is tolerating soft diet and oral fluids
Bilateral pedal pulses 2+
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
The Correct Answer is ["A","B","C","D","E","F","G","H","I","J"]
The client's condition shows signs of improvement as indicated by several findings. The blood glucose level has decreased from 468 mg/dL to 310 mg/dL, which, although still above the normal range, is a significant improvement. The pulse rate has normalized from 110/min to 84/min, and the blood pressure has improved from 96/65 mm Hg to 106/76 mm Hg, indicating better cardiovascular stability. The
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Padding the upper two side rails of the client's bed helps prevent injury during a seizure by reducing the risk of head trauma.
B) Maintaining peripheral IV access may not directly address the client's safety during a seizure.
C) Teaching assistive personnel to apply restraints is not appropriate for managing seizures and may not be indicated unless other safety measures have failed.
D) Keeping a padded tongue blade at the client's bedside is not necessary and may not be safe if the client experiences a seizure.
Correct Answer is B
Explanation
A) Limiting time for visitors is necessary in this case. However, the time should be limited to 1 hour in 24 hours and not 2 hours.
B) Instructing visitors to remain 6 feet from the client is crucial for their safety to minimize radiation exposure. Brachytherapy involves the use of a radioactive source placed close to or inside the tumor, and while the patient is emitting radiation, safety precautions must be taken to protect others from exposure. Safety measures such as maintaining a safe distance help ensure that the radiation exposure to others is As Low As Reasonably Achievable (ALARA), a principle that aims to minimize exposure while achieving the necessary therapeutic effect.
C) Discarding the radioactive device in the client's trash can is incorrect as it poses a risk of exposure to others.
D) Keeping soiled bed linens in the client's room is incorrect as they may be contaminated with radiation and should be handled according to radiation safety protocols.
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