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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 A

Explanation

A. Bringing a sterile chest drainage unit from central supply is a task that does not require clinical judgment and is suitable for a UAP.
B. Calling the pharmacy involves understanding and communication about medications, which should be handled by licensed staff.
C. Observing a client's gait to determine the need for assistance involves assessment and clinical judgment, which is beyond the UAP's scope.

D. Evaluating a client's urinary catheter for proper drainage requires assessment skills that are within the scope of licensed nurses.

A. Events requiring steroid dose adjustments. B. Need to check temperature daily. C. Importance of recording daily weights. D. Adherence to a high fiber, low fat diet.

Correct Answer is A

Explanation

A. Clients with Addison's disease need to understand situations that require an adjustment in their steroid dose, such as stress, infection, or surgery, to prevent an Addisonian crisis.
B. Daily temperature checks are not typically required for Addison's disease unless there is a concern for infection.
C. While daily weights can be helpful in some conditions, it is not the primary focus for managing Addison's disease.

D. Dietary modifications such as high fiber, low fat may be beneficial for overall health but are not specific to managing Addison's disease.

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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

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Explanation

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Correct Answer is A

Explanation

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Patient Data

Exhibits

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