The nurse continues to care for the client.
Click to highlight the findings that indicate improvement in the client's condition. To deselect a finding, click on the finding again.
|
Assessment |
Findings |
|
Nurses' Notes |
Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge. Membranes intact No uterine contractions noted. FHR baseline 138, minimal variability. No further reports of burning with urination. |
|
Laboratory Results |
WBC 12,000/mm3 (5000 to 10000/mm3) Platelet count 188000/mm3 (150000 to 400000/mm3) |
|
Vital Signs |
Temperature 37.1oC (98.7 oF) Blood pressure 120/78 mmHg |
Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge
Membranes intact
No uterine contractions noted
FHR baseline 138, minimal variability
No further reports of burning with urination
WBC 12,000/mm3 (5000 to 10000/mm3)
Platelet count 188000/mm3 (150000 to 400000/mm3)
Temperature 37.1oC (98.7 oF)
Blood pressure 120/78 mmHg
The Correct Answer is ["A","C","E","F","H","I"]
Nurses' Notes:
Client rates lower back pain a 0 on a scale from 0 to 10: Indicates pain resolution, suggesting improvement.
No reports of vaginal discharge: Suggests stabilization and no signs of labor progression.
No uterine contractions noted: Indicates that preterm labor is resolving.
No further reports of burning with urination: Suggests that the urinary tract infection (UTI) is improving.
Vital Signs:
Temperature 37.1°C (98.7°F): Fever has resolved, indicating response to antibiotics.
Blood pressure 120/78 mmHg: Remains stable within normal limits.
Laboratory Results:
WBC 12,000/mm³ (previously 16,000/mm³): Decreasing WBC count suggests resolution of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E","H","I","J","K"]
Explanation
Blood Pressure: 112/74 mmHg (Previously 76/45 mmHg): The client's blood pressure has stabilized, suggesting improved circulatory volume and perfusion.
Heart Rate: 95/min (Previously 121/min): A decrease in heart rate indicates improved hemodynamic stability and a reduced compensatory response to blood loss.
Hemoglobin: 12 g/dL (Previously likely lower due to GI bleeding): Hemoglobin has improved, indicating successful correction of anemia, possibly due to blood transfusion.
Mucous Membranes: Moist and Pink (Previously Pale): Improved mucosal color and hydration suggest better oxygenation and volume status.
General Assessment: No Distress (Previously Diaphoretic, Uncomfortable): The client no longer shows signs of discomfort or distress, indicating symptom relief and better overall condition.
Oxygen Saturation: 100% on 2 L/min Nasal Cannula (Previously 98% on Room air): The client is maintaining adequate oxygenation with minimal supplemental oxygen.
Epigastric Tenderness Without Guarding or Rebound Tenderness: No worsening of GI symptoms suggests that the treatment plan (transfusion, IV fluids, and PPI therapy) is effective.
Correct Answer is B
Explanation
A. Continuous bladder irrigation is not appropriate unless the client has a condition like post-op bleeding from bladder surgery.
B. Low urine output (oliguria) of <30 mL/hr and dark yellow urine suggest dehydration or decreased kidney perfusion, which can be corrected with IV fluid administration.
C. Clamping the catheter could worsen urinary retention and is not appropriate.
D. A urine culture is needed only if infection is suspected, but this scenario suggests dehydration, not infection.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.