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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","E"]

Explanation

A. Serum potassium within the reference range is not typically a cause for concern in this scenario.
B. A hemoglobin A1C level of 7% indicates poor glycemic control and may suggest the need for adjustment in diabetes management, as it exceeds the recommended target range.
C. Total cholesterol within the reference range is not the most significant finding to report in this scenario.
D. Hematocrit within the reference range is not the most significant finding to report in this scenario.
E. A random plasma glucose level of 200 mg/dl (11.1 mmol/L) is indicative of hyperglycemia and requires attention as it suggests poor glycemic control, potentially related to diabetes.

A. Effective coping with illness related anxiety B. Infection prevention related to illness C. Relief of acute pain D. A review of diet progression postoperatively E. Promotion of bowel routine F. Prevention of deep vein thrombosis (DVT) related to immobility G. Fluid volume management H. Client education about diagnosis and plan of care

Correct Answer is ["B","C","G","H"]

Explanation

A. While addressing anxiety is important, it is not the most immediate priority in the emergency setting where acute pain, potential infection, and fluid management take precedence.
B. Given the diagnosis of appendicitis, preventing infection is crucial. The client is at risk for developing an infection or sepsis if the appendix perforates, which could result in peritonitis.
C. The client is experiencing severe abdominal pain (pain rating of 9/10). Effective pain management is essential for the client’s comfort and stabilization.
D. This is more relevant post-surgery. In the emergency department, the focus should be on stabilizing the client and preparing her for surgery.
E. The client has regular bowel movements and this is not a priority in the context of acute appendicitis.
F. This is a consideration for longer-term inpatient care or post-surgery, not an immediate priority in the emergency setting.
G. The client is receiving a bolus of Lactated Ringer’s to manage her fluid volume.

Maintaining adequate hydration and correcting any potential dehydration or fluid imbalance is vital.
H. Educating the client about her diagnosis and the plan of care, including the upcoming surgery, helps reduce anxiety and ensures that she is informed about her treatment.

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

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","E"]

Explanation

Exhibits What goal(s) should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply.

Correct Answer is ["B","C","G","H"]

Explanation

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Patient Data

Exhibits

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