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Patient Data

Exhibits

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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Reconciling medication dosages is important but comes after verifying the accuracy of the prescriptions.
B. Comparing admission prescriptions with the client's previous medication list ensures continuity of care and prevents omissions or duplications.
C. Determining generic versus brand name medications can be addressed later after ensuring medication accuracy.
D. Client teaching is important but should follow the verification of the client's current medications.

A. Remove the transdermal patch until the vomiting subsides. B. Reposition the transdermal patch to the client's trunk. C. Explain that this is a side effect of the medication in the patch. D. Notify the client's healthcare provider of the vomiting.

Correct Answer is D

Explanation

A. Removing the scopolamine patch is not indicated without consulting the healthcare provider.
B. Repositioning the patch is not necessary as it is properly placed for its intended effect.
C. While nausea and vomiting are potential side effects of scopolamine, it's important to notify the healthcare provider to determine the appropriate next steps.
D. Notifying the healthcare provider allows for further evaluation and possible adjustment of the client's postoperative antiemetic regimen.

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Patient Data Exhibits Which assessment findings indicate that the client has stabilized? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older client is being admitted to a rehabilitation unit from a medical-surgical unit following a left hip replacement. When reviewing the client's prescribed medications, which intervention should the nurse implement first?

Correct Answer is B

Explanation

Four hours after surgery, a client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind the ear. Which action should the nurse take?

Correct Answer is D

Explanation

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Patient Data

Exhibits

Which assessment findings indicate that the client has stabilized? Select all that apply.