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 ["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.
Correct Answer is C
Explanation
A. Suggesting the antecubital site does not address the immediate issue of using an inappropriate needle size.
B. Sending a UAP to gather equipment is not an immediate action needed to correct the mistake.
C. Using an 18-gauge needle to irrigate an IV catheter is inappropriate and could damage the catheter. The charge nurse should instruct the new nurse to remove the needle and use a syringe without a needle to perform the irrigation safely.
D. Starting a secondary infusion is unrelated to the irrigation process and does not correct the inappropriate needle use.
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