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 B
Explanation
A) Generalized abdominal pain reported by a client with peritonitis indicates visceral pain.
B) Pain in the left shoulder reported by a client with pancreatitis is an example of referred pain, as it occurs at a site distant from the actual pathology.
C) Substernal chest pain reported by a client with angina indicates cardiac pain, not referred pain.
D) Incisional pain reported by a postoperative client is localized and does not indicate referred pain.
Correct Answer is ["A","B","C","D","E"]
Explanation
A) The client's pain level decreased from 7 to 5 after receiving nitroglycerin. This decrease indicates improvement in the client's condition.
B) The client’s respiratory rate decreased from 24/min to 22/min.
C) The client’s heart rate decreased from 120/min to 100/min.
D) Initially, the client's oxygen saturation was 93% on room air, which decreased to 89%. However, after receiving oxygen at 2 L/min via nasal cannula it improved to 92%.
E) The blood pressure decreased from 176/82 to 110/62.
F) Only one echocardiogram result showing myocardial infarction was provided.
G) Only one reading of I&O was provided showing an output of 32 mL, hence difficult to determine whether there was an improvement.
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