How it Works
Try Naxlex NCLEX-RN (Free-Trial)

The nurse reviews the entries in the medical record.

Exhibits

Click to highlight the findings that indicate improvement in the client's condition. To deselect a finding, click on the finding again.

Laboratory Results

1800:

WBC count 6,700/mm3 (5,000 to 10,000/mm3)

Hemoglobin 12 g/dL (14 to 18 g/dL)

Hematocrit 36% (40% to 52%)

Vital Signs

1800:

Blood pressure 112/74 mm Hg

Heart rate 95/min

Respiratory rate 18/min

Temperature 37.5° C (99.5° F)

Oxygen saturation 100% via 2 L/min nasal cannula

Assessment

1800:

Physical Exam:

General: no distress

HEENT: oropharynx clear, mucous membranes moist and pink

Respiratory: bilateral breath sounds clear

Gl: epigastric tenderness to palpation, no rebound tenderness or guarding

Neuro: awake and alert

A.

WBC count 6,700/mm3 (5,000 to 10,000/mm3)

B.

Hemoglobin 12 g/dL (14 to 18 g/dL)

C.

Hematocrit 36% (40% to 52%)

D.

Blood pressure 112/74 mm Hg

E.

Heart rate 95/min

F.

Respiratory rate 18/min

G.

Temperature 37.5° C (99.5° F)

H.

Oxygen saturation 100% via 2 L/min nasal cannula

I.

no distress

J.

mucous membranes moist and pink

K.

no rebound tenderness or guarding

Answer and Explanation

The Correct Answer is ["B","D","E","H","I","J","K"]

Blood Pressure: 112/74 mmHg (Previously 76/45 mmHg): The client's blood pressure has stabilized, suggesting improved circulatory volume and perfusion.

Heart Rate: 95/min (Previously 121/min): A decrease in heart rate indicates improved hemodynamic stability and a reduced compensatory response to blood loss.

Hemoglobin: 12 g/dL (Previously likely lower due to GI bleeding): Hemoglobin has improved, indicating successful correction of anemia, possibly due to blood transfusion.

Mucous Membranes: Moist and Pink (Previously Pale): Improved mucosal color and hydration suggest better oxygenation and volume status.

General Assessment: No Distress (Previously Diaphoretic, Uncomfortable): The client no longer shows signs of discomfort or distress, indicating symptom relief and better overall condition.

Oxygen Saturation: 100% on 2 L/min Nasal Cannula (Previously 98% on Room air): The client is maintaining adequate oxygenation with minimal supplemental oxygen.

Epigastric Tenderness Without Guarding or Rebound Tenderness: No worsening of GI symptoms suggests that the treatment plan (transfusion, IV fluids, and PPI therapy) is effective.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is D

Explanation

A. Limiting potassium intake is incorrect because hypokalemia increases the risk of digoxin toxicity.
B. If the child vomits after taking digoxin, the dose should NOT be repeated, as it may be due to toxicity.
C. Digoxin should NOT be mixed with large amounts of liquid, as the child may not finish it, leading to an incomplete dose.
D. Drinking water helps remove residual digoxin from the mouth, preventing irritation and ensuring the full dose is swallowed.

Correct Answer is D

Explanation

A. Incorrect – The client should be placed in a supine position, not high-Fowler’s.
B. Incorrect – Dentures should be left in place to maintain facial appearance.
C. Incorrect – Arms should be placed at the sides or across the abdomen, not crossed over the chest.
D. Correct – Gently holding the eyes shut prevents them from remaining open, helping maintain a natural appearance.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register