Exhibits
The nurse is reviewing the client's medical record. Which of the following findings indicates the client's condition has improved? Select all that apply.
Echocardiogram results
Blood pressure
Urinary output
Pain level
Respiratory rate
Heart rate
Oxygenation saturation
Correct Answer : B,D,E,F,G
Echocardiogram results would provide information about the structure and function of the heart, particularly regarding any changes in cardiac function or wall motion abnormalities that might have been detected during the acute phase. It does indicate signs of improvement.
B. Blood pressure is an important vital sign that reflects cardiovascular status. In the context of acute coronary syndrome or myocardial infarction, a stable or improving blood pressure indicates adequate perfusion to vital organs, including the heart. A decrease in blood pressure from hypertensive levels seen earlier could indicate stabilization of the client's condition.
C. Urinary output is a critical indicator of renal perfusion and function. During acute illness, including cardiac events, decreased urinary output can indicate poor perfusion due to decreased cardiac output or hypoperfusion. In this scenario the output is still inadequate.
D. Pain level, specifically chest pain in the context of acute coronary syndrome, is a subjective indicator of the client's cardiac status. A reduction in pain intensity, as reported by the client, can indicate that the treatment, such as nitroglycerin for angina, is effective in relieving myocardial ischemia. Therefore, a decrease in pain level suggests improvement in the client's cardiac condition.
E. Respiratory rate is another vital sign that reflects the client's respiratory effort and overall respiratory status. In the context of acute cardiac events, respiratory rate can increase due to pain, anxiety, or respiratory distress. A decrease in respiratory rate suggests improved respiratory comfort and potentially reduced cardiac workload, indicating improvement in the client's condition.
F. Heart rate is a crucial vital sign that reflects cardiac workload and rhythm. In acute coronary syndrome, tachycardia is often present due to sympathetic stimulation and the body's response to myocardial ischemia. A decrease in heart rate suggests that the client's cardiac workload has decreased, possibly indicating improved myocardial perfusion and stability.
G. Oxygen saturation reflects the amount of oxygen bound to hemoglobin in the blood, which is essential for tissue oxygenation. In acute cardiac events, hypoxemia can occur due to impaired cardiac function or respiratory compromise. Improvement in oxygen saturation indicates improved tissue oxygenation, possibly due to effective management of cardiac function or respiratory support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Petechiae indicate a risk of bleeding due to low platelet levels or dysfunction. Bleeding precautions aim to minimize the risk of injury and bleeding events.
A While knowing the blood type is generally important for medical management, it is not the immediate priority based on the presence of petechiae alone.
C. Intravenous pain medications, especially those that can affect platelet function (like NSAIDs), may increase the risk of bleeding.
D. Airborne precautions are used for diseases transmitted by airborne droplets smaller than 5 microns, such as tuberculosis or measles. Petechiae are not indicative of an airborne disease transmission risk.
Correct Answer is D
Explanation
D. A weight loss of 1.8 kg (4 lb) in the past 24 hours indicates effective diuresis (urine output) and reduction in fluid volume, which is the therapeutic goal of furosemide in treating pulmonary edema.
A Furosemide is a loop diuretic that typically causes a decrease in blood pressure by promoting the excretion of excess fluid and sodium from the body.
B. Adventitious breath sounds such as crackles (rales) indicate the presence of fluid in the lungs, which is a characteristic finding in pulmonary edema.
C. A respiratory rate of 24 breaths per minute is within normal range for an adult at rest. While this respiratory rate is not abnormal, it also does not directly indicate whether furosemide is effective in treating pulmonary edema.
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