Practice Question
A nurse is caring for an adolescent who presents to the emergency department
Answer Choices:
Rationale:
🟦 1. Lung sounds — Improved
🟦 At 1500, the adolescent had dry cough and wheezing in the upper lobes, indicating airway obstruction likely due to fluid retention from heart failure.
🟦 By 1930, documentation shows only mild wheezing, demonstrating a less severe respiratory obstruction.
🟦 This improvement aligns with the expected response to furosemide, which removes excess fluid and reduces pulmonary congestion.
🟦 While not fully resolved, the decrease in wheezing indicates better ventilation and improved cardiopulmonary status.
🟩 2. Dyspnea — Improved
🟩 At 1500, dyspnea was present even while sitting upright, indicating significant respiratory distress and poor cardiac output.
🟩 By 1930, the adolescent reports dyspnea only with activity, meaning resting breathing has improved.
🟩 This pattern matches expected improvement after oxygen therapy and diuretic administration.
🟩 Activity-related dyspnea is typical in heart failure, but improvement at rest shows better oxygenation and reduced pulmonary congestion.
🟧 3. Blood Pressure — Improved
🟧 Initial BP was 143/92, showing elevated afterload commonly seen in heart failure exacerbation.
🟧 By 1930, BP decreased to 129/72, reflecting better cardiac workload and afterload reduction.
🟧 This improvement is consistent with the action of enalapril, an ACE inhibitor that reduces vascular resistance.
🟧 Improved BP supports enhanced cardiac efficiency and stabilization.
🟨 4. Respiratory Rate — Improved
🟨 The initial respiratory rate of 26/min indicated compensatory tachypnea due to poor oxygenation and fluid overload.
🟨 At reassessment, RR decreased to 20/min, which falls within the normal range for adolescents.
🟨 This demonstrates reduced respiratory effort and improved gas exchange after diuresis and oxygen therapy.
🟨 A normalized respiratory rate signals improved cardiopulmonary function.
🟪 5. Heart Rate — Improved
🟪 The apical pulse was 110/min, showing tachycardia—often a compensation for low cardiac output in heart failure.
🟪 By 1930, the heart rate dropped to 92/min, indicating reduced cardiac stress and improved ventricular function.
🟪 Digoxin improves contractility, allowing the heart to work more efficiently with fewer beats.
🟪 Lower HR reflects stabilization and better hemodynamic status.
🟫 6. Oral Intake — Improved
🟫 At 1500, the adolescent had not eaten for 3 days, indicating poor perfusion, fatigue, and possibly dyspnea that interfered with eating.
🟫 By 1930, the adolescent ate a portion of their dinner tray, showing improved energy level and respiratory comfort.
🟫 Adequate oral intake is a crucial indicator of improving systemic and metabolic stability.
🟫 This reflects better overall functioning and symptom relief.
🟩 7. Oxygen Saturation — Improved
🟩 Initial oxygen saturation was 94% on room air, which is borderline low for adolescents.
🟩 By 1930, saturation increased to 97% on 2 L/min oxygen, demonstrating more effective gas exchange.
🟩 The improved saturation is consistent with reduced pulmonary edema after diuretic therapy.
🟩 This result indicates improved clinical stability and better oxygen delivery to tissues.
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This question is from Custom NURS2221 unit VI Exam 2025 which contains 45 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN Custom Exam(s)
- Answer Choices: 0