Exhibits Click to indicate which client goal is being met by each of the client data. Each column must have at least one response selected.
Explanation & Rationale
Blood pressure 112/77 mmHg: Indicates adequate perfusion and stabilized blood pressure, which is a sign of successful hypovolemia management after trauma and fluid resuscitation. Capillary refill 2 seconds: A normal capillary refill time suggests that peripheral circulation is stable, which helps in managing hypovolemia and maintaining adequate tissue perfusion. pH 7.40: A normal pH supports the concept of ventilation support being effective and adequate. A normal pH indicates appropriate respiratory function and acid-base balance. PaCO2 42 mmHg: A normal PaCO2 suggests that the client’s ventilation is adequate and CO2 is being eliminated appropriately, which is part of ventilation support. Surgical dressing dry and intact: This observation indicates that there is no significant infection risk at the incision site. Keeping surgical dressings dry and intact helps prevent infection. Pain 0 on a scale of 0 to 10: The client reports no pain, which indicates effective pain and anxiety control, providing comfort and minimizing stress. Temperature 98.1°F (36.7°C): A normal body temperature indicates that there is no active infection or fever, supporting the goal of infection prevention.