A nurse is caring for a client in the emergency department. Click to highlight the findings that indicate that the client's conditions improving. To deselect a finding, click on the finding again 1400: Client admitted to the medical-surgical unit at 1200 today. Alert and orientated x4, heart and lung sounds clear. Client urinating 100 ml/hour Client is tolerating soft diet and oral fluids. Bowel sounds are hyperactive in a 4 quadrants. Bilateral pedal pulses 2+. Blood glucose 310 mg (74 to 106 mg/dL) 1400: Temperature 36.8° C (98.2° F) Pulse rate 84/min Respiratory rate 16/min Blood pressure 106/76 mm Hg Oxygen saturation 96% on room air
Explanation & Rationale
Rationale for correct findings: • Client urinating 100 mL/hour: Adequate urine output demonstrates improved renal perfusion and hydration, confirming that fluid resuscitation is effective. It also indicates that the kidneys are responding appropriately to metabolic correction. • Bilateral pedal pulses 2+: Stronger peripheral pulses reflect improved perfusion and intravascular volume after IV fluid therapy. This demonstrates recovery from the initial hypovolemic effects. • Blood pressure 106/76 mm Hg: The increase from earlier hypotension shows improved hemodynamic stability and tissue perfusion. This is a positive sign that fluid resuscitation and metabolic management are effective. • Pulse rate 84/min: The reduction from 110/min indicates decreased compensatory tachycardia and improved cardiovascular stability, reflecting recovery from dehydration and hyperglycemia. Rationale for incorrect findings: • Blood glucose 310 mg/dL: Although decreased from 468 mg/dL, blood glucose is still above the normal range (74–106 mg/dL). This shows partial improvement but ongoing hyperglycemia requires continued insulin therapy.