The nurse is reviewing the client's medical record.
Which of the following findings indicates the client's condition has improved? Select all that apply.
Blood pressure
Echocardiogram results
Respiratory rate
Pain level
Oxygenation saturation
Urinary output
Heart rate
Correct Answer : A,C,D,E,G
Improvement in blood pressure would suggest better cardiovascular stability
A stable or decreased respiratory rate would indicate improved respiratory function and potentially reduced chest tightness.
An increase in oxygen saturation levels would indicate improved respiratory function and cardiovascular status.
A decrease in pain level would indicate improvement in the chest tightness and radiating pain experienced by the client.
A decrease in heart rate may indicate improved cardiovascular function and reduced stress on the heart.
Urinary output and echocardiogram results are not typically immediate indicators of improvement in the client's condition following an episode of chest tightness and radiating pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. The vestibulocochlear nerve is responsible for both the vestibular function and the cochlear function. Impaired function of the vestibulocochlear nerve could result in symptoms related to vestibular dysfunction, such as disequilibrium (feeling unsteady or off balance) especially with movement.
A. The olfactory nerve (cranial nerve I) is responsible for the sense of smell.
B. Loss of peripheral vision is typically associated with impairment of the optic nerve (cranial nerve II), which is responsible for vision.
D. Deviation of the tongue occurs in injury to the hypoglossal nerve.
Correct Answer is D
Explanation
D. A thrill is a palpable vibration or buzzing sensation felt over the graft site, caused by turbulent blood flow. In the context of an arteriovenous graft, a palpable thrill is typically considered a positive finding, indicating adequate circulation through the graft. It suggests that blood is flowing smoothly from the arterial to the venous side of the graft.
A. The presence of a bruit is typically considered a positive finding, indicating adequate blood flow through the graft. Therefore, the absence of a bruit may indicate inadequate circulation or a potential complication such as graft occlusion or stenosis.
B. Normal blood pressure is not a specific indicator of the adequacy of circulation through an arteriovenous graft.
C. A dilated appearance of the graft may suggest venous hypertension or increased pressure within the graft. While this could indicate adequate blood flow, it may also suggest problems such as venous stenosis or thrombosis, which can impede circulation through the graft.
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