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Exhibits

Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.

Electrocardiogram: Tall T wave and widened QRS complex

Blood pressure: 126/76 mm Hg

Basilar crackles

Urine output: 20 mL in the last hour

Respirations: 26 breaths/minute

Heart rate: 72 beats/minute

Oxygen saturation 98% on room air

A normal body temperature (98.9°F or 37.1°C orally).

Answer and Explanation

Correct Answer : B,F,G,H

A. An electrocardiogram with a tall T wave and widened QRS complex may indicate electrolyte imbalances or cardiac issues, which are not indicative of stabilization.

C. Basilar crackles can be a sign of pulmonary or cardiac issues and are not indicative of stabilization.

D. A urine output of 20 mL in the last hour may suggest reduced kidney function or hydration status and is not indicative of stabilization.

E. A respiratory rate of 26 breaths/minute may indicate respiratory distress and is not indicative of stabilization.

The assessment findings that suggest stabilization include:

A blood pressure within the normal range (126/76 mm Hg).

A heart rate within the normal range (72 beats/minute).

Oxygen saturation of 98% on room air, indicating adequate oxygenation.

A normal body temperature (98.9°F or 37.1°C orally).

These vital signs and clinical parameters are within normal ranges, suggesting that the client's condition is stable at this time.

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Correct Answer is D

Explanation

A. Documenting the client's relief of pain is important for the medical record but is not the first priority in this situation. The immediate concern is to determine the cause of the sudden pain relief and ensure the child's well-being.

B. Inquiring about the client's last meal is important for pre-operative considerations, but it is not the first action to take when sudden relief of abdominal pain is reported.

C. Giving prescribed intravenous antibiotics may be part of the treatment plan, but it should not be the first action when the child experiences sudden relief of abdominal pain. Contacting the healthcare provider to assess the situation is more urgent.

D Contact the healthcare provider.

In the case of a child diagnosed with appendicitis, sudden relief in abdominal pain can be concerning. This might indicate that the appendix has ruptured, leading to the spread of infection into the abdominal cavity, which can be a critical situation. It's essential for the healthcare provider to be informed immediately so they can assess the child's condition, order any necessary interventions, and potentially expedite the surgical procedure if required.

A. Reactions to any previous hospitalizations. B. A history of rubella, rubeola, or chicken pox. C. Mother's use of alcohol, drugs, or cigarettes during pregnancy. D. List of achievement timeline for developmental milestones.

Correct Answer is A

Explanation

A. Reactions to any previous hospitalizations can provide some insight into the child's previous healthcare experiences, but it may not be as directly relevant to planning care for an umbilical hernia repair.

B. A history of rubella, rubeola, or chicken pox is important for the child's medical history, but it may not be the most critical information when planning care for an umbilical hernia repair.

C. The mother's use of alcohol, drugs, or cigarettes during pregnancy is particularly relevant when planning care for a child undergoing surgery, as it can affect the child's overall health and potential complications during and after the procedure. Exposure to these substances during pregnancy can lead to various health issues that need to be considered in the child's care plan.

D. A list of achievement timeline for developmental milestones is important for understanding the child's developmental progress, but it may not be the primary consideration when planning care for an umbilical hernia repair.

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Exhibits Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 9-year-old admitted to the unit with severe abdominal pain and fever is diagnosed with appendicitis and is placed on the surgery schedule for an appendectomy. The child reports to the nurse of experiencing sudden relief in abdominal pain. Which action should the nurse take first?

Correct Answer is D

Explanation

A six-year-old girl is being admitted to the hospital for repair of an umbilical hernia. Which information, collected by the admitting nurse, is particularly helpful in planning care for this child?

Correct Answer is A

Explanation

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Exhibits

Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.