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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) 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.

A. Infuse 0.99% sodium chloride if the solution is not available. B. Obtain the client's weight daily. C. Monitor serum blood glucose during infusion. D. Verify the solution with another RN prior to infusion. E. Increase the rate of infusion if administration is delayed.

Correct Answer is ["B","C","D"]

Explanation

A) Infusing 0.9% sodium chloride is incorrect as it's not appropriate for TPN administration.
B) Obtaining the client's weight daily helps to monitor nutritional status and adjust TPN accordingly.
C) Monitoring serum blood glucose is essential due to the high glucose content in TPN, which can lead to hyperglycemia.
D) Verifying the solution with another RN prior to infusion is a safety measure to ensure the correct solution and dosage.
E) Increasing the rate of infusion if administration is delayed may lead to complications and is not appropriate without medical orders.

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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.