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The nurse is reviewing the client's medical record.

Exhibits

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

Answer and Explanation

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.

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Correct Answer is C

Explanation

C. Morphine is a central nervous system depressant that can help decrease anxiety and relieve dyspnea in clients with acute heart failure. Therefore, a decrease in anxiety would indicate that the medication has been effective in achieving its intended outcome.
A. Emesis, or vomiting, is not an expected outcome of morphine administration in the context of acute heart failure.
B. While morphine can help alleviate dyspnea, an increased respiratory rate may indicate respiratory distress rather than effective symptom relief.
D. Morphine does not directly affect urinary output, and a decrease in urinary output may indicate other issues such as renal dysfunction or fluid overload.

A. Apply mitten restraints to prevent the client from disconnecting their tube feeding. B. Apply a vest restraint daily at bedtime to prevent nighttime wandering. C. Apply an abduction pillow between the client's knees while they are in bed to prevent hip dislocation. D. Apply soft heel protectors bilaterally while client is in bed.

Correct Answer is B

Explanation

Restraints should be avoided whenever possible. Addressing the underlying cause of wandering (such as anxiety, discomfort, or confusion) is essential.
A. In cases where restraints are deemed necessary to prevent harm to the client, such as preventing them from dislodging their tube feeding, it may be appropriate.
C. The use of an abduction pillow is a common preventive measure to maintain proper hip alignment and prevent hip dislocation, especially after hip surgery.
D. Soft heel protectors are used to prevent pressure ulcers and protect the heels from injury while the client is in bed.

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The nurse is reviewing the client's medical record. Exhibits Which of the following findings indicates the client's condition has improved? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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The nurse is reviewing the client's medical record.

Exhibits

Which of the following findings indicates the client's condition has improved? Select all that apply.