The nurse is continuing to care for the client.
A nurse is evaluating the client's response to therapy. Which of the following recent findings indicate the client's condition has improved or not changed? For each assessment finding, click to specify if the finding indicates that the client's condition has improved or has not changed.
Heart rate
Blood pressure
Edema
Deep tendon reflexes
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}
|
Finding |
Improved |
Not changed |
|
Heart rate |
|
✓ |
|
Blood pressure |
✓ |
|
|
Edema |
✓ |
|
|
Deep tendon reflexes |
✓ |
|
Rationale
- Heart rate: Not changed
- The heart rate increased from 72/min to 90/min, indicating no improvement.
- Blood pressure: Improved
- The blood pressure decreased from 166/110 mm Hg to 152/90 mm Hg, indicating improvement.
- Edema: Improved
- The edema decreased from +3 pitting to +2 pitting, indicating improvement.
- Deep tendon reflexes: Improved
- The patellar reflex decreased from 4+ to 2+, indicating improvement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Fibrinogen level: Fibrinogen is involved in clot formation but is not used to monitor warfarin.
B. INR: INR reflects the client’s clotting tendency and is essential for determining the appropriate warfarin dose. Therapeutic INR ranges typically vary based on the indication (e.g., 2.0–3.0 for atrial fibrillation).
C. Platelet count: Important for assessing bleeding risk, but it does not measure warfarin's efficacy.
D. aPTT: Used to monitor heparin therapy, not warfarin.
Correct Answer is C
Explanation
A. The NG tube should be flushed with 15-30 mL of water before and after medication administration, not 5 mL.
B. Medications should not be added directly to enteral feeding as it may alter the medication's effectiveness or cause tube clogging.
C. Using a syringe to allow medications to flow by gravity reduces the risk of pressure-related complications and ensures safe administration.
D. Medications should be dissolved separately to prevent interactions or clogging.
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