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The nurse is reviewing the client's medical record.

Exhibits

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.

Pain level

Respiratory rate

Heart rate

Oxygenation saturation

Blood pressure

Echocardiogram results

Urinary output

Answer and Explanation

Correct Answer : A,B,C,D,E

A)   The client's pain level decreased from 7 to 5 after receiving nitroglycerin. This decrease indicates improvement in the client's condition.
B)   The client’s respiratory rate decreased from 24/min to 22/min.
C)   The client’s heart rate decreased from 120/min to 100/min.

D) Initially, the client's oxygen saturation was 93% on room air, which decreased to 89%. However, after receiving oxygen at 2 L/min via nasal cannula it improved to 92%.
E) The blood pressure decreased from 176/82 to 110/62.

F) Only one echocardiogram result showing myocardial infarction was provided.

G) Only one reading of I&O was provided showing an output of 32 mL, hence difficult to determine whether there was an improvement.

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Correct Answer is B

Explanation

A. Changing dressings is important but not the priority over assessing cardiac status in an electrical shock injury.
B. Obtaining an ECG is the priority to assess for any cardiac dysrhythmias, which can be immediate and life-threatening consequences of electrical shock injuries.
C. Administering pain medication can be done once the client's cardiac status has been evaluated and stabilized.
D. While maintaining adequate urine output is important, assessing cardiac status takes precedence.

A. Wear an N95 respirator when providing direct client care. B. Make sure the client's room has positive-pressure airflow. C. Make sure dietary plates and utensils are disposable. D. Monitor the client's temperature once every 6 hr.

Correct Answer is B

Explanation

A) While wearing an N95 respirator may be necessary for certain infections, it is not a routine precaution for clients in protective isolation.
B) Ensuring the client's room has positive-pressure airflow helps prevent the entry of airborne pathogens into the room, reducing the risk of infection for the immunocompromised client.
C) Using disposable plates and utensils helps reduce the risk of cross-contamination and infection transmission but is not directly related to airborne infection control.
D) Monitoring the client's temperature is important for assessing for signs of infection, but it does not directly prevent infection transmission in the same way as positive-pressure airflow.

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The nurse is reviewing the client's medical record. Exhibits 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.

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The nurse is reviewing the client's medical record.

Exhibits

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.