HESI

When assessing a client, the nurse auscultates a murmur at the second left intercostal space (ICS) along the sternal border. This reflects sound from which valve?

Pulmonic

The nurse performs a respiratory assessment and auscultates breath sounds that are high pitched, creaking, and accentuated on expiration. Which term best describes the findings?

Wheezes

An adolescent is taken to the emergency department of the local hospital after stepping on a nail. The puncture wound is cleansed and a sterile dressing applied. The nurse asks if the client has had a tetanus immunization. The adolescent responds that all immunizations are up to date. Penicillin is administered, and the client is sent home with instructions to return if there is any change in the wound area. A few days later, the client is admitted to the hospital with a diagnosis of tetanus. Legally, what is the nurse's responsibility in this situation?

Assessment by the nurse was incomplete and, as a result, the treatment was insufficient The nurse's data collection was not adequate because the nurse did not ask about the date of the previous tetanus inoculation. The nurse failed to support the life and well-being of a client. The nurse's assessment was not thorough in regard to determining the date of immunization. It was essential to determine when the client was last immunized; for a "tetanus-prone" wound, like a puncture from a rusty nail, some form of tetanus immunization usually is given. Administering immunization against tetanus is not an independent function of the nurse.

A nurse is teaching a client about measures to promote health. Which statements made by the client indicate effective learning? Select all that apply. I will assess my own pulse rate after exercising I will follow my hypertension treatment plan consistently I will perform a self-assessment of my heart rate using the carotid pulse I will ask my caretaker to check my blood pressure at a different time of day.

I will assess my own pulse I will follow my hypertension treatment plan I will perform a self-assessment of my heart rate Assessing the pulse rate after exercising is helpful in knowing the impact of exercise on the pulse rate. Following the hypertension treatment plan consistently will help the client stay healthy. Performing a heart rate self-assessment using the carotid pulse is also effective in promoting health. This action will also help the client to know if there are any abnormalities related to the pulse rate. An aneroid sphygmomanometer is a sophisticated device that requires recalibration more than once a year. Blood pressure should be measured at the same time every day for accurate results.

A client reports vomiting and diarrhea for 3 days. Which clinical indicator is most commonly used to determine whether the client has a fluid deficit?

Loss of body weight Dehydration is measured most readily and accurately by serial assessments of body weight; 1 L of fluid weighs 2.2 lb (1 kg). Although dry skin may be associated with dehydration, it also is associated with aging and some disorders (e.g., hypothyroidism). Although hypovolemia eventually will result in a decrease in blood pressure, it is not an accurate, reliable measure because there are many other causes of hypotension. Altered appearance is too general and not an objective determination of fluid volume deficit.

The nurse is assessing a client following abdominal surgery. Which assessment findings should the nurse use to form a data cluster? Select all that apply. The client reports pain with movement The client has pain over the surgical area The client wants to know when he can go home The client rates pain as an 8 on a scale of 0 to 10 The client has concerns about caring for the wound

The client reports pain without movement The client has pain over the surgical area The client rates the pain as 8 on a scale of 0 to 10. The nurse groups all information that contains a defining characteristic such as pain. The nurse clusters all assessments related to pain. The client reports pain with movement. The clinical criteria are observable and verifiable. The nurse learns that the pain is over the surgical area and not an underlying pain. The nurse verifies and measures the data by rating the pain as 8 on a scale of 0 to 10. The client wants to know when he can go home, but this assessment is not related to the pain. The client is also worried about caring for the wound, but this assessment will belong to a different cluster

While caring for a client with heat stroke, the nurse measured the temperature and noted it as 109o F. Convert this temperature into Celsius and record your number using one decimal place.

42.8

A client who sustained head injuries is admitted to the hospital. During assessment of cranial nerves, the nurse notices that the client lost the perception of taste, especially in the anterior portion of the tongue. Which cranial nerve might have been injured in this client?

CN VII Cranial nerve VII is the facial nerve. Injury to the facial nerve limits the sensory impulses from the anterior two-thirds of the tongue, along with altered facial expressions. Cranial nerve X is the vagus nerve, injury to which causes limitation of palatal movements. Cranial nerve IX is the glossopharyngeal nerve. Injury to this nerve results in loss of taste impulses from the posterior one-third of the tongue. Cranial nerve XII is the hypoglossal nerve, damage of which results in improper movements of the tongue.

Which error will result in false high diastolic readings while measuring a client's blood pressure during a physical examination?

Inflating the cuff too slowly Inflating or deflating the cuff too slowly will yield false high diastolic readings. Wrapping the cuff too loosely will result in false high systolic and diastolic values. Applying the stethoscope too firmly will result in false low diastolic readings. Repeating the assessment too quickly will result in false high systolic readings.

A nurse must establish and maintain an airway in a client who has experienced a near-drowning in the ocean. For which potential danger should the nurse assess the client?

Pulmonary Edema Additional fluid from surrounding tissues will be drawn into the lung because of the high osmotic pressure exerted by the salt content of the aspirated ocean water; this results in pulmonary edema. Hypoxia and acidosis may occur after a near-drowning, not alkalosis. Renal failure is not a sequela of near-drowning. Hypovolemia occurs because fluid is drawn into the lungs by the hypertonic saltwater.

The nurse is caring for an elderly client with dementia. Which client need should the nurse prioritize while providing care?

Safety

While performing a physical assessment in a client, the registered nurse (RN) notices reddish linear streaks in the nail bed. Which systemic condition can the registered nurse (RN) suspect in the client based on these assessment findings?

Subacute bacterial endocarditis Red or brown linear streaks in the nail bed are caused by minor trauma to nails, subacute bacterial endocarditis, or trichinosis and are called splinter hemorrhages. Conditions such as syphilis and iron deficiency anemia cause concavely curved nails, called koilonychia. Heart and lung abnormalities such as chronic obstructive pulmonary disease cause clubbing of the nail beds.

A client who does not understand English requires an interpreter. Which nursing student action may exacerbate health disparities?

The student only talks to the interpreter about the client.

During a physical assessment, a client was diagnosed with increased temperature due to an increased basal metabolic rate (BMR). Which hormonal imbalances may the client have? Select all that apply. Cortisol Thyroid Estrogen Testosterone Progesterone

Thyroid Testosterone Body temperature is assessed during physical assessment. An increased basal metabolism rate increases the body temperature. Hormonal imbalances may alter the basal metabolic rate (BMR). Testosterone regulates the BMR in males. Thyroid hormone regulates the BMR of the body. Increases in the levels of these hormones may increase the BMR, which may in turn raise body temperature. Cortisol regulates blood glucose levels. Estrogen and progesterone are female hormones that do not regulate the BMR.

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer?

unstageable

A client develops an allergic reaction when a student nurse is performing a physical assessment. Which statement made by the student nurse in response to this incident indicates the need for further teaching?

"the client's first exposure to latex will cause a type IV allergic reaction" Both type I and type IV hypersensitive reactions require prior exposure to cause an immune response in a subsequent exposure. The most immediate immune response is a type I reaction, in which the body produces IgE antibodies against the allergen. A type IV immune response occurs 12 to 48 hours after the exposure to the allergen and is referred to as a delayed hypersensitivity response.

While conducting an assessment, the nurse finds that the client shivers uncontrollably and experiences memory loss, depression, and poor judgment. What might the client's body temperature be?

33 degrees C A body temperature in the range of 36° to 38 ° C is normal. When skin temperature drops below 35° C, the client may exhibit uncontrolled shivering, loss of memory, depression, and poor judgment as a result of hypothermia. A body temperature lower than 30° C represents severe hyperthermia. In this condition, the client will demonstrate a lack of response to stimuli and extremely slow respiration and pulse. Based on the signs given, the client's temperature is most likely 33° C.

During an assessment, the client complains of tenderness when the nurse palpates the calf muscle. What would be the nurse's next assessment?

To evaluate for swelling, warmth, and muscle firmness Tenderness at the site of calf muscle may indicate phlebitis. Other symptoms of phlebitis include swelling, warmth, and muscle firmness at the site. Reduced hair growth or a history of recurring ulcers may indicate circulatory insufficiency. Venous distension in the anterior or medial part of the thigh indicates varicosities.

While assessing a client's skin, a nurse notices that the skin is dry. What is the probable etiology of the condition? Select all that apply. Use of hard soap Frequent bathing Use of tanning pills Presence of an allergy Use of petroleum

Use of hard soap Frequent bathing

A nurse is assessing a client who was admitted with a head injury that occurred 4 days ago and is diagnosed with an injury to the speech center in the cerebral cortex. Upon further assessment, the nurse finds that the client is unable to understand written or verbal speech. Which condition does the nurse suspect?

Aphasia Aphasia of the receptive type is a condition in which the client cannot understand written or verbal speech. This may be due to injury to the cerebral cortex. Dysarthria is a motor speech disorder in which the client has difficulty speaking caused by impairment of the muscles used in speech. Borborygmi are rumbling noises made by the movement of fluid and gas in the intestine. Tactile fremitus is the vibration created during speech by the vocal cords when sound is transmitted through the lung to the chest wall.

A client reports to the nurse sleeping until noon every day and taking frequent naps during the rest of the day. What should the nurse do initially?

Arrange a referral for a thorough medical evaluation This behavior is a sign of hypersomnia, and the client needs a medical assessment; it is commonly caused by central nervous system damage or certain kidney, liver, or metabolic disorders. Exercise is appropriate for a client experiencing insomnia, not hypersomnia. This behavior is a sign of hypersomnia, and medical causes should be ruled out before attributing it to a psychogenic cause. Narcolepsy consists of recurrent sudden waves of overwhelming sleepiness that occur during the day, even during activities such as eating or conversing.

The nurse is assessing a client who reports breathlessness. Which activity best ensures that the nurse obtains accurate and complete data to prevent a nursing diagnostic error?

Assess the client's lungs The nurse should assess the client's lungs to gather objective data that will support subjective data provided by the client. The nurse can obtain objective data for this client by auscultating for lung sounds, assessing the respiratory rate, and measuring the client's chest excursion. The nurse should review the data for accuracy and completeness before grouping the data into clusters. The nurse may also assess the client for pain, which is subjective data. The client may provide details about smoking habits, which is also subjective data. It is important for the nurse to identify what causes breathlessness; however, the client's statement is subjective data. All subjective data must be supported by measurable objective data.

The registered nurse is teaching a nursing student about bulimia nervosa in adolescents. Which statement made by the nursing student indicates effective learning?

Binge eating

Which clients should be considered for assessing the carotid pulse? Select all that apply. Client with cardiac arrest Client indicated for Allen test Client under physiologic shock Client with impaired circulation to foot Client with impaired circulation to hand

Client with cardiac arrest Client under physiologic shock Carotid pulse is indicated in clients with physiologic shock or cardiac arrest when other sites are not palpable in the client. Assessment of the ulnar pulse is indicated in clients requiring an Allen test. Assessment of posterior tibial pulse and dorsalis pedis pulse is indicated in clients with impaired circulation to the feet. Assessment of the radial and ulnar pulse is indicated in clients with impaired circulation to the hands.

The nurse is performing a breast assessment. Which statement made by the client indicates the risk of breast cancer? Select all that apply. I had a late onset of menarche My first child was born when I was 32 I noticed a slight discharge from nipple I perform breast self-examinations frequently I consume two to four glasses of alcohol a day

My first child was born when I was 31 I noticed a slight discharge from my nipple I consume two to four glasses of alcohol a day Clients who gave birth to a first child after the age of 30 are at a risk of breast cancer. Discharge from the nipple may indicate an early symptom of breast cancer. Consuming two to four glasses of alcohol daily may also increase the risk of breast cancer. An early onset of menarche is a risk factor for breast cancer. Performing breast self-examinations frequently may help to identify the early stages of breast cancer.

While assessing a client's range of motion, the nurse explains adduction to the nursing student. Which statement made by the nursing student indicates effective learning?

"I will ask the client to move his or her arm towards the body"

Which statements related to initial assessment of hypertension by the nurse requires correction? Select all that apply. 1. "Deflating the cuff too slowly will show false-high diastolic readings." 2. "The stethoscope applied too firmly against the antecubital fossa will show a low systolic reading." 3. "If the blood pressure in the left arm is 110/80 mm Hg and in the right arm it is 130/80 mm Hg, it is reportable." 4. "Having the client's arm unsupported while assessing blood pressure will result in a false low reading of blood pressure." 5. "It is normal to have blood pressure of 110/80 mm Hg in the left arm and blood pressure of 120/80 mm Hg in the right arm."

2 4 False low diastolic readings are obtained in clients if the stethoscope is held too firmly against the antecubital fossa. Keeping the arm unsupported while assessing blood pressure results in false high blood pressure values. False high diastolic readings are obtained when the cuff is deflated too slowly. Pressure differences greater than 10 mm Hg between the two arms should be reported because it indicates vascular problems. Normally there is a difference of 5 to 10 mm Hg of blood pressure between the arms.

Which scenario is most likely to contribute to health disparities?

An english-speaking nurse provides discharge instructions to an English-speaking client who is hard of hearing As per the U.S. Department of Health and Human Services Office of Minority Health, health care organizations should offer and provide language assistance services, including an interpreter, to each client with limited English proficiency at all points of contact during all hours of operation and service. Therefore, presence of an interpreter is essential for the admission interview of a Puerto Rican immigrant with limited knowledge of English. A Hispanic client in a coma is not able to speak, so an interpreter is not necessary. Interpreter service is not required while the nurse plans nursing procedures because the nurse does not interact with the client directly during this phase. Although the nurse must ensure that the hard-of-hearing client can hear discharge instructions, there is lower risk for health disparities since the nurse and the client speak the same language.

The nurse is preparing to teach a client about self-injection of insulin. Which action by the nurse will increase the effectiveness of the teaching session?

Assess the client's barriers to learning self-injection techniques Before a teaching plan can be developed, the factors that interfere with learning must be identified. Although family members can be helpful, client involvement in care is most important for promoting independence and self-esteem. Assessment comes before intervention; written instructions may not be the most appropriate teaching modality. The client may never accept the change but must learn to manage care; this may be an unrealistic expectation.

A client was admitted to a surgical unit in an unconscious state due to head trauma. Which site would be most appropriate to obtain the client's temperature?

Axilla The axilla would be the most appropriate site to obtain a temperature measurement in a client who is unconscious due to head trauma. The oral route is not accessible when the client is unconscious. Because the client is in a surgical unit, his or her head may be covered. Therefore, obtaining a temperature measurement through the temporal artery or tympanic membrane may not be possible.

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client?

Blood lab results Blood lab results provide objective data about fluid and electrolyte status, as well as about hemoglobin and hematocrit. Skin turgor is not a reliable indicator of hydration status for the elderly client because it is generally decreased with age. Intake and output results provide data only about fluid balance, but do not present a comprehensive picture of the client's fluid and electrolyte status; therefore this is not the best answer. The client's report about fluid intake is subjective data in general and not reliable because this client has dementia and therefore has memory problems.

A client with severe bleeding due to a motor vehicle accident was admitted to the emergency department. The nurse assessed that the client was unconscious and the healthcare provider diagnosed the client with a hand fracture. The client is receiving oxygen therapy as well as intravenous fluids through the antecubital fossa. Which sites should be used to obtain the client's pulse rate? Select all that apply Apical Carotid Brachial Femoral Popliteal

Carotid Femoral Clients with severe bleeding may develop hypovolemic shock. The carotid and femoral pulses are easily accessible sites to measure pulses in clients with hypovolemic shock. The apical pulse may not be palpable in a client with hypovolemic shock. Because the client is diagnosed with a hand fracture and is receiving intravenous fluids through the antecubital fossa, the brachial artery cannot be accessed to measure the pulse rate. The popliteal site is used to assess the status of the circulation in the lower leg.

The nurse assesses an elderly client with a diagnosis of dehydration and recognizes which finding as an early sign of dehydration?

Change in mental status Older adults are sensitive to changes in fluid and electrolyte levels, especially sodium, potassium, and chloride. These changes will manifest as a change in mental status and confusion. It is difficult to assess dehydration in older adults based on sunken eyes, dry skin, and decreased bowel sounds because these can be prominent as general normal findings in the elderly client.

While assessing the nails of a client with diabetes, the nurse finds that the skin on the client's hands and feet are dry due to infection. What could be the reason for this dryness?

Cutting nails after soaking them 10 minutes in warm water Normally, nails should be cut after soaking them in warm water for 10 minutes. This action should not be performed for diabetic clients because soaking the nails will dry out the hands and feet, which may lead to infection. Applying moisturizing lotion between the toes will promote microorganism growth; it will not dry the skin. Cutting nails straight across and even with the tops of the fingers or toes is the proper way to maintain nail hygiene. Diabetic clients are advised not to use sharp objects to poke or dig under the toenails or around the cuticles to avoid injury to the skin.

The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this pulse can be characterized as what?

Full

While performing a neck assessment, the nurse finds the client has enlarged lymph nodes. The client also had a history of intravenous drug use and bisexual activity. What would be the possible diagnosis?

HIV infection The presence of enlarged lymph nodes may indicate infection. Further findings of intravenous drug use and bisexual activity may indicate an HIV infection. Cancer may be detected by enlarged lymph nodes; however the history of drug use and bisexual activity would not necessarily point to a cancer diagnosis. Neck swelling and changes in hair texture, skin texture, or nails coupled with a change in emotional stability may indicate thyroid disease. A history of a bronchial tumor or pneumothorax may lead to tracheal displacement.

A client complains of difficulty breathing. The nurse auscultates wheezing in the anterior bilateral upper lobes. What could be the possible reason for this sound?

High velocity airflow through an obstructed airway Wheezing is a high-pitched sound that may be caused by a high velocity airflow through an obstructed or narrowed airway. Inflammation of the pleura may produce pleural friction rubs. Muscular spasms in larger airways or any new growth causing turbulence may produce rhonchi, which is a loud and low-pitched sound. Sudden reinflation of groups of alveoli may produce crackling sounds.

While assessing a client, a nurse finds that the ratio of the anteroposterior diameter and transverse diameter of the chest is 1:1. What is indicated by this finding? Select all that apply. Client has lordosis Client is an older adult Client has osteoporosis Client has a history of smoking Client has chronic lung disease

Older adult history of smoking chronic lung disease The 1:1 ratio of the anteroposterior diameter and transverse diameter of the chest indicates a barrel-shaped chest. This is a characteristic feature in an older adult who smokes and has chronic lung disease. In lordosis, there is an increase in lumbar curvature. Osteoporosis is a systemic skeletal condition in which there is a decreased bone mass and deterioration of bone tissue.

The nurse suspects that an intraoperative client has a distended bladder. Which method is correct to assess for this condition?

Percuss and palpate the hypogastric region To detect a distended bladder, percussion and palpation should be performed over the hypogastric region of the abdomen. Percussion of a distended bladder would produce a dull sound and feel firm on palpation. Inspecting and palpating in the epigastric region, auscultating and percussing in the inguinal areas, or percussing and palpating bilaterally in the lumbar areas are all inaccurate procedures to assess for a distended bladder.

A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock?

Restlessness In the early stage of shock, the client has increased epinephrine secretion. This, in turn, causes the client to become restless, anxious, nervous, and irritable. Decreased respiratory rate is a late sign of shock. A urine output of 30 mL/hour is within normal limits. Lethargy is not a sign of shock.

Which related factor is appropriate for a nursing diagnosis?

Trauma of incision

A nursing student under the supervision of a registered nurse is performing a pulse assessment. While preparing to assess the client, the registered nurse asks the nursing student to check the apical pulse after assessing the radial pulse. What could be the reason behind for this change?

The client may have dysrhythmia A client with dysrhythmia may have an intermittent or abnormal radial pulse. For this condition, the registered nurse should advise the nursing student to assess the apical pulse because it will be more accurate. If the client is in shock, then assessing the carotid or femoral pulse would be appropriate. The femoral pulse is preferred to assess a client with peripheral artery disease.

Following assessment, a nurse documents auscultation of course rhonchi in the anterior upper lung fields bilaterally that clears with coughing. What would be the cause of these sounds?

Turbulence due to muscular spasm and fluid or mucus in the larger airways Loud, low pitched, rumbling coarse sounds heard over the trachea and bronchi are due to turbulence caused by muscular spasm when fluid or mucous is present in the larger airways. Pleural rub produces a dry or grating quality sound, best heard in the lower portion of the anterior lateral lung. Random and sudden reinflation of groups of alveoli produces crackling sounds predominantly heard in the left and right lung bases. High-velocity airflow through severely narrowed or obstructed airways results in a wheezing sound heard all over the lung.

The nurse is overseeing a nursing student who is conducting an assessment of a client who does not speak English. No interpreter is available. Which action requires further teaching?

Using medical terminology Nurses should follow certain guidelines when interpreter is not available while assessing a client who does not understand English. Rather than using medical terminology, the nursing student should use simple, more well-known words, like "pain" instead of "discomfort." The nursing student's other actions are appropriate. Proceeding in an unhurried manner; speaking in a low, moderate voice; and pantomiming words and simple actions while verbalizing them promote effective communication.

While performing a physical assessment of a female client, the nurse positions the client in Sims' position. Which body system will be assessed in this position? Select all that apply. heart vagina rectum female genitalia

Vagina Rectum Sims' position is indicated to examine vagina and rectum. Lithotomy to check female genitalia. Lateral recumbent position will aid in detecting murmurs of the heart. Prone position is indicated while assessing the musculoskeletal system.

Which client is suspected to have an increased risk of hyperlipidemia? Select all that apply. Client with corneal arcus Client with periorbital edema Client with decreased skin turgor Client with paleness of conjunctivae Client with yellow lipid lesions on eyelids

corneal arcus yellow lipid lesions on eyelids The presence of corneal arcus, which is the whitish opaque ring around the junction of the cornea and sclera, indicates that the client has hyperlipidemia. Yellow lipid lesions on the eyelids refer to xanthelasma, which indicates a client has hyperlipidemia. The presence of periorbital edema indicates the client may have kidney disease. Decreased skin turgor may be due to dehydration. Paleness of the conjunctivae indicates anemia.

Which clients suffer from impaired near vision? Select all that apply. A client with myopia A client with presbyopia A client with hyperopia A client with retinopathy A client with macular degeneration

Presbyopia Hyperopia A loss of elasticity of the lens causes impaired near-vision in presbyopia. Light rays focusing behind the retina are the cause of impaired near vision in clients with hyperopia. Myopia is caused by a refractive error where the light rays focus in front of the retina. Retinopathy is a noninflammatory change in the retinal blood vessels. Macular degeneration is a blurring of central vision caused by progressive degeneration of the central retina.

Which sites would the nurse prefer while assessing for turgor in an older adult? Select all that apply. Back of the neck Back of the hand Palm of the hand On the sternal area Back of forearm

On the sternal area Back of the forearm Turgor indicates the elasticity of the skin. The ideal site to assess the skin for turgor in an older adult is back of the forearm or the sternal area. The back of the neck contains redundant skin and may not be reliable. The skin on the back of the hand is normally loose and thin; turgor assessed at that site may not be reliable. The palm of the hand is not an ideal site for the assessment of turgor.

A client with a history of cardiac dysrhythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. The registered nurse is assessing the vital signs recorded by the student nurse. Which vital sign assessments require reassessment based on the data given by the student nurse? Select all that apply. Respiratory rate of 14 breaths/minute Blood pressure of 120/80 mmHg Oxygen saturation of 95% Temporal temp of 37.4 degrees C

Respiratory rate Blood pressure Oxygen Saturation In pulmonary infections, the respiratory rate may increase and oxygen saturation may decrease. In fluid volume deficit, the blood pressure may be decreased. A respiratory rate of 14 breaths/minute, a blood pressure of 120/80 mmHg, and an oxygen saturation of 95% are normal readings. Therefore, the registered nurse should reassess these vital signs. The normal temperature range is 36 to 38 0C; this range is unaffected by a pulmonary infection. Therefore, the nurse does not need to reassess the temperature. Cardiac dysrhythmias are associated with a pulse deficit in which the radial pulse would be irregular. Therefore reassessment would not be required.

A 50-year-old client with a 30-year history of smoking reports a chronic cough and shortness of breath related to chronic obstructive pulmonary disease (COPD). The clinical data on admission are as follows: a heart rate of 100, a blood pressure of 138/82, a respiratory rate of 32, a tympanic temperature 36.8 °C, and an oxygen saturation of 80%. Which vital signs obtained by the nurse during the therapy indicates a positive outcome? Select all that apply. Radial pulse: 70 Temperature: 37 degrees C Respiratory rate: 14 Blood pressure: 110/70 Oxygen Saturation: 92%

Respiratory rate: 14 Blood pressure: 110/70 Oxygen saturation: 92% The respiratory rate ranges in older adults from 12 to 20 breaths/min and this range may be elevated in clients with chronic obstructive pulmonary disease (COPD). Thus a rate decrease to 14 breaths/min indicates a positive outcome. COPD may also cause high blood pressure. Thus, a blood pressure of 110/70 obtained during therapy indicates a positive outcome. The normal oxygen saturation rate should be 95 to 100%. An oxygen saturation increase from 88% to 92% indicates a positive outcome of the therapy. The radial pulse indicates a positive outcome of the therapy if the client has a history of heart disease. A body temperature reading of 36.8 °C is considered normal and not a sign of COPD