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Serum albumin Is to be administered intravenously to client with ascites, The expected outcome of this treatment will be a decrease in:
- A. Urinary output
- B. Serum ammonia level
- C. Abdominal girth
- D. Hepatic encephalopathy
Correct Answer: C
Rationale: The correct answer is C: Abdominal girth. Serum albumin helps to increase oncotic pressure in the blood vessels, reducing fluid leakage into the abdomen and decreasing ascites, leading to a decrease in abdominal girth. Option A is incorrect because serum albumin does not directly affect urinary output. Option B is incorrect as serum albumin does not directly impact serum ammonia levels. Option D is incorrect because while serum albumin can help improve liver function, it does not directly treat hepatic encephalopathy.
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A client is admitted with a serum glucose of 618mg/dl. The client is awake and oriented, with hot, dry skin; a temperature of 100.6F (38.1 C); a heart rate of 116beats/min; and a blood pressure of 108/70mmHg. Based on these findings, which nursing diagnosis takes highest priority?
- A. Deficient fluid volume related to osmotic diuresis
- B. Decreased cardiac output related to increased heart rate
- C. Imbalanced nutrition: Less than body requirements related to insulin deficiency
- D. Ineffective thermoregulation related to dehydration
Correct Answer: A
Rationale: The correct answer is A: Deficient fluid volume related to osmotic diuresis. With a serum glucose level of 618mg/dl, the client is likely experiencing diabetic ketoacidosis, leading to excessive urination (osmotic diuresis) and dehydration. The priority is to address fluid volume deficit to prevent hypovolemic shock. The other options are not the priority because: B: Decreased cardiac output is a result of the increased heart rate, not the primary issue. C: Imbalanced nutrition is important but not as urgent as fluid volume deficit. D: Ineffective thermoregulation is a concern but not the priority in this scenario.
A patient is diagnosed with acute bacterial conjunctivitis. In providing patient teaching the nurse would tell the patient that this condition is more commonly known as which of the following?
- A. Glaucoma
- B. Color blindness
- C. Astigmatism
- D. Pinkeye
Correct Answer: D
Rationale: The correct answer is D: Pinkeye. Acute bacterial conjunctivitis is commonly referred to as "pinkeye" due to the characteristic pink or red appearance of the eye. This condition is caused by a bacterial infection of the conjunctiva, the thin membrane that covers the white part of the eye and inner eyelids. The term "glaucoma" (A) refers to a different eye condition characterized by increased intraocular pressure, while "color blindness" (B) is a genetic condition affecting color vision. "Astigmatism" (C) is a refractive error related to the shape of the cornea or lens, not an infection of the eye. Therefore, the correct answer is D as it accurately identifies the common name for acute bacterial conjunctivitis.
A client was brought to the emergency room with complains of difficulty of breathing. What can lead the nurse to suspect that the client is experiencing acute respiratory distress syndrome (ARDS)?
- A. paO2 of 95, pCO2 of 43, x-ray showing enlarged heart, bradycardia
- B. Thick green sputum production, paO2 of 74, pH of 7.41
- C. restlessness, suprasternal retractions, paO2 of 62
- D. wheezes, slow, deep respirations, pCO2 of 52, pH of 7.35
Correct Answer: C
Rationale: Step-by-step rationale for choice C being correct:
1. Restlessness: Indicates increased work of breathing and hypoxia.
2. Suprasternal retractions: Sign of respiratory distress.
3. paO2 of 62: Indicates severe hypoxemia, common in ARDS.
Summary:
A: Enlarged heart on x-ray does not directly indicate ARDS.
B: Thick green sputum suggests infection, not specific to ARDS.
D: Wheezes and slow respirations are not typical of ARDS, and pCO2 is normal in ARDS.
The nurse is assigned to a client with polymyositis. Which expected outcome in the plan of care relates to a potential problem associated with polymyositis?
- A. “Client will lose 2lb per week on a calorie-restricted diet.”
- B. “Client will exhibit no signs or symptoms of aspiration.”
- C. “Client will exhibit bowel and bladder continence.”
- D. “Client will exhibit alertness and orientation to person, place, and time.” DISTURBANCES IN IMMUNOLOGIC FUNCTIONING
Correct Answer: E
Rationale: I'm sorry, but it seems like the correct answer (E) is missing from the question. Could you please provide the correct answer so that I can provide you with a detailed explanation of why it is correct and summarize why the other choices are incorrect?
Which of the ff is a sign of urinary retention in older adults with a neurologic deficit?
- A. Amnesia
- B. Hypertension
- C. Hypotension
- D. A behaviour change
Correct Answer: D
Rationale: The correct answer is D, a behavior change. Urinary retention in older adults with a neurologic deficit can manifest as a behavior change, such as increased agitation, confusion, or restlessness due to discomfort from the inability to empty the bladder. Amnesia (A) is memory loss and not directly related to urinary retention. Hypertension (B) and hypotension (C) are related to blood pressure regulation and are not specific signs of urinary retention. In contrast, a behavior change (D) is a common and characteristic sign indicating urinary retention in this population.