Exhibits
Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.
A.
Electrocardiogram: Tall T wave and widened QRS complex
B.
Blood pressure: 126/76 mm Hg
C.
Basilar crackles
D.
Urine output: 20 mL in the last hour
E.
Respirations: 26 breaths/minute
F.
Heart rate: 72 beats/minute
G.
Oxygen saturation 98% on room air
H.
A normal body temperature (98.9°F or 37.1°C orally).
The Correct answer and Explanation is:
Correct answers:
B. Blood pressure: 126/76 mm Hg
F. Heart rate: 72 beats/minute
G. Oxygen saturation 98% on room air
H. A normal body temperature (98.9°F or 37.1°C orally)
Explanation:
When evaluating whether a patient has stabilized, several clinical parameters need to be assessed, including vital signs, oxygenation, and cardiac status. Below is a detailed breakdown of why certain findings indicate stability:
- B. Blood pressure: 126/76 mm Hg
This blood pressure reading is within the normal range for adults, where a systolic blood pressure below 120-130 mm Hg and a diastolic pressure below 80 mm Hg are considered optimal. A stabilized blood pressure suggests effective circulation and adequate cardiac output, a key indicator that the client has stabilized. - F. Heart rate: 72 beats/minute
A heart rate between 60-100 beats per minute is generally considered normal for adults. A heart rate of 72 beats/min indicates that the client’s cardiac function is stable and well-regulated, without signs of tachycardia or bradycardia, which could signify instability. - G. Oxygen saturation: 98% on room air
Normal oxygen saturation levels range from 95% to 100%. A reading of 98% suggests that the client has adequate oxygenation and lung function, with no need for supplemental oxygen. This indicates respiratory stability and effective gas exchange. - H. Normal body temperature (98.9°F or 37.1°C orally)
A body temperature of 98.9°F (37.1°C) is considered normal, signifying that the client is not experiencing fever or hypothermia. This suggests that the client’s thermoregulatory mechanisms are functioning properly and no infection or inflammatory response is ongoing.
Abnormal findings:
- A. Electrocardiogram: Tall T wave and widened QRS complex
This finding is concerning and often associated with hyperkalemia (high potassium levels), which can cause life-threatening cardiac arrhythmias. It suggests the client may not be fully stabilized yet. - C. Basilar crackles
Crackles in the lungs are abnormal breath sounds that may indicate fluid in the alveoli, commonly associated with heart failure or pneumonia. This finding points to unresolved respiratory or cardiac issues. - D. Urine output: 20 mL in the last hour
Normal urine output for an adult is around 30 mL/hr or more. A low urine output of 20 mL in one hour indicates potential renal impairment or decreased perfusion, suggesting instability. - E. Respirations: 26 breaths/minute
The normal respiratory rate for adults is 12-20 breaths per minute. A rate of 26 breaths per minute indicates tachypnea, which could be a sign of respiratory distress or compensation for metabolic imbalances.
Therefore, the correct answers (B, F, G, H) reflect stabilized vital signs and oxygenation, whereas abnormal findings like elevated respiratory rate, crackles, and low urine output would indicate instability.