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The nurse evaluates the effectiveness of actions. Which of the following findings indicate effectiveness? Select all that apply.

1. Pain is reported 6/10

2. UA is obtained

3. Vomit x 2

4. Fever of 101.4 °F

5. Urinary strainer shows crystals

6. Acetaminophen level is 180

7. Normal sinus rhythm noted on monitor

8. BP 160/100

User Darxtrix
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1 Answer

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Final answer:

Findings that indicate the effectiveness of nursing actions in this scenario would include obtaining a urine sample (UA obtained), identifying crystals with a urinary strainer, and observing a normal sinus rhythm on the monitor.

Step-by-step explanation:

The question asks which findings indicate the effectiveness of nursing actions. An effective nursing intervention would result in a positive change in the patient's condition or vitals. Some options here are clearly not indicative of improvement, such as persistent pain or high blood pressure, while others may signify positive outcomes.

  • UA obtained: This suggests a successful collection of a urine sample, potentially for diagnostic purposes.
  • Urinary strainer shows crystals: If the nursing actions were related to monitoring for kidney stones or urinary issues, the presence of crystals could indicate the effectiveness of those actions by showing successful identification of the problem.
  • Normal sinus rhythm noted on monitor: This finding indicates that the patient's heart rhythm is normal, suggesting effective management of any previous arrhythmias or stabilization of the patient's condition.

The other options, such as a fever of 101.4 °F or a blood pressure of 160/100, generally represent conditions that a nurse would aim to improve, not signs of effective intervention. An isolated acetaminophen level would require context to understand its significance; it could either be a therapeutic level or indicate toxicity, depending on the context of the patient scenario and the dosing.

User Joep Weijers
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