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 D
Explanation
Thawed FFP should be administered promptly. It can be stored at 1 to 6 degrees Celsius for up to 24 hours if not used immediately. However, it is best to administer it as soon as possible after thawing.
A. FFP should be administered through a larger-bore intravenous catheter (typically 18-20 gauge) to prevent clotting or clogging of the line.
B. The recommended infusion time for FFP is approximately 30 minutes to 1 hour. Rapid infusion helps maintain clotting factor activity.
C. FFP is specifically used to manage bleeding due to coagulopathy. If the client is actively bleeding, timely FFP administration is crucial.
Correct Answer is C
Explanation
C. Stridor is a high-pitched, crowing sound that occurs during inspiration and indicates upper airway obstruction. Stridor following extubation is a concerning finding and requires immediate intervention to ensure adequate airway patency and prevent respiratory compromise. The nurse should notify the healthcare provider immediately and be prepared to provide interventions such as airway suctioning, supplemental oxygen, or reintubation if necessary.
A. While a sore throat is a common complaint after extubation due to irritation from the endotracheal tube, it does not typically require immediate intervention unless it is severe or accompanied by other concerning symptoms. The nurse should provide comfort measures and monitor for worsening symptoms.
B. An SPO2 of 92% is within normal rage and requires no immediate intervention.
D. While rhonchi may require intervention, they are not typically as immediately concerning as stridor, which indicates upper airway obstruction.
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