LPN Nursing · GI and Renal Disorders in Children · Practice question
Patient's Data. Click to highlight the findings from EHR that indicate improvement in the child's condition. To deselect a finding, click on the finding again.
Nurse’s Notes
Day 3, 1000:
The child is sitting up in the chair watching TV. The child reports pain in the left leg as 2 on a scale from 0 to 10. Respirations even and non-labored. Scattered rhonchi to posterior bases. Abdomen is hard and distended. Bowel sounds active in 4 quadrants. Surgical wound edges well approximated. No edema or warmth present over surgical incision. Partial weight bearing left leg. Immobilizer brace intact. Weight 35.9 kg (79.2 lb).
Vital Signs
Day 3, 1000:
Temperature 37.4° C (99.4° F) aural
Heart rate 100/min
Respiratory rate 22/min
Blood pressure 114/70 mm Hg
Pulse oximetry 99% on room air
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Nurses' Notes, Day 3, 1000: The child is sitting up in the chair watching TV. The child reports pain in the left leg as 2 on a scale from 0 to 10. Respirations even and non-labored. Scattered rhonchi to posterior bases. Abdomen is hard and distended. Bowel sounds active in 4 quadrants. Surgical wound edges well approximated. No edema or warmth present over surgical incision. Partial weight bearing left leg. Immobilizer brace intact. Weight 35.9 kg (79.2 lb). Vital Signs, Day 3, 1000: Temperature 37.4° C (99.4° F) Heart rate 100/min Respiratory rate 22/min Blood pressure 114/70 mm Hg Pulse oximetry 99% on room air
Answer & explanation
Correct:
When comparing Day 3 findings to the initial presentation, several findings indicate clinical improvement. The child's pain has decreased from 7/10 to 2/10, reflecting reduced inflammation and effective pain management. The absence of edema or warmth over the surgical incision suggests resolution of localized infection and improved tissue status. The child being up in the chair and performing partial weight bearing on the left leg demonstrates improved functional ability. The temperature has decreased from 38.6°C to 37.4°C, indicating that the fever is resolving, which is a key marker of infection control. The heart rate has decreased from 116/min to 100/min, showing improvement in the tachycardia that accompanied the febrile state. Pulse oximetry has improved from 96% to 99%, reflecting better oxygenation status. Respiratory rate remains at 22/min and is not an improvement. Blood pressure of 114/70 is slightly higher than 100/68 but not a marker of improvement per se and reflects stable hemodynamics. The scattered rhonchi to posterior bases and hard, distended abdomen are new concerning findings that do not represent improvement. Bowel sounds remain active. Therefore, the nurse's notes segment containing pain, wound findings, and mobility, along with temperature, heart rate, and pulse oximetry from the vital signs, best represent improvement.
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