Patient Data
Which assessment findings indicate that the client has stabilized? Select all that apply.
Oxygen saturation 98% on room air
Urine output 20 mL in the last hour
Basilar crackles
Heart rate 72 beats/minute
Respiratory rate 26 breaths/minute
Blood pressure 126/76 mm Hg
Electrocardiogram Tall T wave and widened QRS complex
Temperature 98.9° F (37.1° C) orally
Correct Answer : A,D,E,F,H
A. Oxygen saturation of 98% on room air indicates that the client is maintaining adequate oxygenation without the need for supplemental oxygen.
B. A urine output of 20 ml within the last one hour is insufficient and could indicate an acute kidney injury.
C. Presence of crackles indicates ongoing pulmonary involvement, which does not suggest stabilization.
D. A heart rate within the normal range for a 7-year-old child (70-120 beats/minute), showing improvement from the previously irregular and elevated rate.
E. Respiratory rate of 26 breaths/minute is now within the normal range for a child (20-30 breaths/minute), indicating improved respiratory function.
F. A blood pressure of 126/76 mm Hg is within the normal range for a child.
G. Tall T wave and widened QRS complex suggest hyperkalemia, which is a serious condition and does not indicate stabilization.
H. An oral temperature of 37.1 C Indicates that the fever has resolved, suggesting that the infection or inflammatory response is under control.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
The incision dressing is dry and intact, with no bleeding noted: This indicates that the surgical site is healing well without any signs of infection or complications. A dry and intact dressing suggests that there is no active bleeding or wound drainage, which is a positive sign of wound healing.
The client has tolerated clear liquids post-recovery and has advanced to a soft diet: Progression from clear liquids to a soft diet indicates that the client's gastrointestinal function is returning to normal. This progression suggests that there are no immediate concerns regarding postoperative nausea, vomiting, or bowel obstruction.
The client has ambulated around the unit and tolerated activity well: Ambulation and tolerance of activity demonstrate the client's physical mobility and overall strength. Being able to move around the unit without difficulty suggests that the client is recovering well from the surgical procedure and is regaining strength and function.
Bowel sounds are present in all 4 quadrants, and the client has passed flatus: The presence of bowel sounds in all four quadrants indicates normal gastrointestinal motility and function. Passing flatus is another positive sign of gastrointestinal recovery, suggesting that the client's bowels are active and functioning properly post-surgery.
Pain is tolerated with analgesia orally: The client's ability to tolerate pain with oral analgesia indicates effective pain management and suggests that the surgical incision site is not causing significant discomfort or distress. Effective pain control is essential for postoperative comfort and can facilitate the client's recovery process.
Correct Answer is D
Explanation
A. While concerning, a single refusal to eat is not immediately life-threatening.
B. While being yelled at could escalate, the situation is not as urgent as others.
C. While refusing to participate in group is concerning, it is not immediately life- threatening.
D. Pacing in a client with bipolar disorder may indicate agitation or the onset of a manic episode, which could lead to dangerous behavior and requires immediate attention.
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