Chest x-ray: Consolidation in the right lower lobe consistent with pneumonia Review H and P, nurse's notes, flow sheet, doctor's order, and Imaging studies.
What statements indicate the client's confusion is resolving?
Select all that apply.
Asks how long he has been in the hospital
Drinking broth
States he is hungry
Clawing at the air
Keeps trying to get out of bed to find the swimming pool
Recognizes his daughter
Oriented to time, place, and self
Oxygen saturation on 0.5L of 100%
Correct Answer : A,B,C,F,G
Based on the given information, the statements that indicate the client's confusion is resolving are:
- Asks how long he has been in the hospital: This shows cognitive awareness and the ability to ask relevant and coherent questions.
- States he is hungry: This indicates a return to normal appetite and the ability to recognize and express basic needs.
- Recognizes his daughter: This demonstrates the ability to recognize and identify a familiar individual, suggesting an improved level of cognitive functioning.
- Oriented to time, place, and self: Being aware of the current time, location, and personal identity reflects an improved level of orientation and mental clarity.
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The statement "Drinking broth" does reflect the client's willingness and ability to consume food.
The following statements suggest ongoing confusion or potential issues:
- Clawing at the air: This behavior may indicate restlessness, agitation, or disorientation.
- Keeps trying to get out of bed to find the swimming pool: This behavior may indicate confusion or an altered perception of reality.
The statement "Oxygen saturation on 0.5L of 100%" provides information about the client's oxygen saturation level but does not specifically address the resolution of confusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Hives (also known as urticaria) are raised, red, itchy welts on the skin that can be caused by an allergic reaction to medication, including antibiotics. It is essential for the PN to recognize this potentially severe allergic reaction and take immediate action.
Immediate action steps include:
- Stop the infusion of the intravenous antibiotic immediately.
- Notify the healthcare provider and report the allergic reaction.
- Assess the client's airway, breathing, and circulation to ensure there are no signs of respiratory distress or anaphylaxis.
- Administer prescribed emergency medications if needed (e.g., epinephrine, antihistamines).
- Monitor the client closely for any further signs of an allergic reaction or anaphylaxis.
The other assessment findings mentioned are also important to address, but they do not require immediate action:
A- Dry mouth with thirst: This may indicate dehydration, which should be addressed by encouraging the client to drink fluids, but it does not pose an immediate threat to the client's safety.
B- Warm skin with elastic turgor: This suggests that the client is adequately hydrated, and the skin's elasticity is normal, which is a positive finding.
C- Low-grade fever with diaphoresis: A low-grade fever indicates a mild elevation in temperature, and diaphoresis (sweating) may be the body's response to regulate temperature. The PN should monitor the client's temperature and assess for other signs of infection, but this finding does not require immediate action
Correct Answer is A
Explanation
Collecting fingerstick glucose levels is the most important intervention for the PN to implement for a client who is receiving TPN. TPN is a method of feeding that bypasses the gastrointestinal tract and provides all the nutritional needs of the body through a vein. TPN contains a high concentration of glucose, which can cause hyperglycemia or fluctuations in blood sugar levels. Therefore, it is essential to monitor the client's glucose levels frequently and adjust the infusion rate or insulin administration accordingly.
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