The nurse is collecting data on the client on the morning of day 2.

Exhibits
Which of the following data collection findings indicate an improvement in the client's condition? Select the 4 findings that indicate an improvement.

Orientation

Blood pressure

Temperature

WBC count

Hallucinations

Answer and Explanation

Correct Answer : A,B,C,E

Rationale:

• Orientation: The client was previously disoriented to time and place, thinking it was 1975 and they were at home. On Day 2, they are alert and fully oriented. This improvement shows enhanced neurological and cognitive status.

• Blood pressure: On Day 1, the client’s BP was 88/50 mm Hg, which indicated hypotension. By Day 2, the BP improved to 132/86 mm Hg. This indicates stabilization of cardiovascular function and better perfusion.

• Temperature: The fever rose to 39.1°C on Day 1 but decreased to 37.7°C on Day 2. This drop suggests the client is responding to treatment and the infectious process is being controlled.

• Hallucinations: On Day 1, the client reported spiders crawling on them, indicating delirium. On Day 2, they deny hallucinations. This improvement shows resolving infection or neuroinflammation.

• WBC count: The WBC count of 14,000/mm³ remains elevated above the normal range and was only assessed on Day 1. Without follow-up labs, it does not indicate improvement.

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Correct Answer is A

Explanation

Rationale:

A. "Prednisone can cause blood glucose levels to increase”: Prednisone is a corticosteroid that can increase blood glucose by promoting gluconeogenesis and reducing cellular glucose uptake. Monitoring glucose levels is important, especially in clients receiving moderate to high doses.

B. "Albuterol treatments can cause blood glucose levels to decrease.": Albuterol is more likely to cause mild hyperglycemia due to its beta-agonist activity, which can stimulate glycogenolysis. It does not typically cause a drop in blood glucose levels.

C. "Having COPD causes blood glucose levels to fluctuate.": COPD alone does not directly cause blood glucose fluctuations. However, glucose changes are more commonly influenced by treatments like corticosteroids rather than the disease itself.

D. "Older adults are at risk for developing type 1 diabetes mellitus.”: Type 1 diabetes is typically diagnosed in children and young adults due to autoimmune beta-cell destruction. Older adults are more at risk for type 2 diabetes, not type 1.

A. Temperature B. WBC count C. Allergies D. Chest x-ray

Correct Answer is C

Explanation

Rationale:

• Temperature: An elevated temperature of 39.3° C is consistent with an active infection like pneumonia. This finding supports the need for antibiotic treatment and does not delay administration unless linked to an adverse drug reaction.

• WBC count: A WBC count of 16,000/mm³ indicates leukocytosis, which is expected in bacterial pneumonia. It confirms infection and the need for antibiotics, not a reason to withhold cefazolin.

• Allergies: The client has a documented allergy to penicillin, which is critical because cefazolin is a cephalosporin. Cephalosporins share a similar beta-lactam structure and can cross-react in clients with penicillin allergies, increasing the risk of anaphylaxis. Reporting this ensures safe prescribing and prevents a life-threatening hypersensitivity reaction.

• Chest x-ray: The left lower lobe density confirms pneumonia. This imaging supports the clinical decision to administer antibiotics and does not warrant withholding the prescribed medication.

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The nurse is collecting data on the client on the morning of day 2. Exhibits Which of the following data collection findings indicate an improvement in the client's condition? Select the 4 findings that indicate an improvement.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of an older adult client who has COPD and is receiving albuterol treatments and 20 mg of prednisone twice daily. The client asks why the nurse is checking his blood glucose level. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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The nurse is collecting data on the client on the morning of day 2.

Exhibits
Which of the following data collection findings indicate an improvement in the client's condition? Select the 4 findings that indicate an improvement.