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Which of the ff symptoms is observed in the client with Right Sided Heart Failure?
- A. Dependent pitting edema
- B. Orthopnea
- C. Exertional dyspnea
- D. Hemoptysis CARING FOR CLIENTS UNDERGOING CARDIOVASCULAR SURGERY
Correct Answer: A
Rationale: Rationale: Right-sided heart failure leads to fluid backup in the body causing dependent pitting edema due to fluid accumulation in the lower extremities. Orthopnea and exertional dyspnea are typically seen in left-sided heart failure. Hemoptysis is associated with conditions like pulmonary embolism or lung cancer, not right-sided heart failure. Therefore, the correct answer is A as it directly correlates with the symptoms of right-sided heart failure.
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A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention?
- A. “Do you feel like you need to go to the bathroom?”
- B. “Are you able to walk to the bathroom by yourself?”
- C. “When was the last time you took your medicine?” NursingStoreRN
- D. “Do you have a safety rail in your bathroom at home?”
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Asking if the patient feels the need to go to the bathroom helps assess urgency.
2. Urinary retention may lead to the inability to sense the urge to void.
3. This question directly addresses the issue of voiding, crucial in diagnosing urinary retention.
Summary:
B: Mobility is not directly related to urinary retention.
C: Medication timing is important but not directly related to urinary retention.
D: Safety rail inquiry is more related to fall prevention, not urinary retention.
Which of the following is the function of macrophages and neutrophils?
- A. Phagocytosis
- B. Complement fixation
- C. Antibody production
- D. Suppression of autoimmunity
Correct Answer: A
Rationale: The correct answer is A: Phagocytosis. Macrophages and neutrophils are both types of phagocytes responsible for engulfing and digesting pathogens such as bacteria. This process helps in clearing infections and maintaining immune homeostasis.
Summary:
- Choice B (Complement fixation) is incorrect as it refers to a process where complement proteins bind to pathogens to enhance their removal by phagocytes.
- Choice C (Antibody production) is incorrect as macrophages and neutrophils do not produce antibodies. They mainly rely on phagocytosis for pathogen clearance.
- Choice D (Suppression of autoimmunity) is incorrect as these cells are involved in innate immunity and do not play a direct role in regulating autoimmunity.
Which drug class is used to reduce symptoms of muscle weakness from myasthenia gravis?
- A. Anticholinesterase drugs
- B. Adrenergic drugs
- C. Anticholinergic drugs
- D. Beta-blocker drugs
Correct Answer: A
Rationale: The correct answer is A: Anticholinesterase drugs. These drugs increase acetylcholine levels at neuromuscular junctions, helping improve muscle strength in myasthenia gravis. Adrenergic drugs (B) and beta-blocker drugs (D) are not typically used to treat muscle weakness in myasthenia gravis. Anticholinergic drugs (C) can worsen symptoms by blocking acetylcholine receptors, making them an inappropriate choice for this condition.
Victorio is being managed for diarrhea. Which outcome indictes that fluid resuscitation is successful?
- A. he passess formed stools at regular intervals
- B. he reports a decrease in stool frequency and liquidity
- C. he exhibits frim skin turgor
- D. he no longer experiences perianal burning
Correct Answer: C
Rationale: The correct answer is C because firm skin turgor indicates adequate hydration, a key goal of fluid resuscitation in diarrhea management. Firm skin turgor reflects the body's fluid balance and hydration status. When fluid resuscitation is successful, the patient's skin turgor improves due to replenished fluid levels. Choices A, B, and D are incorrect as they do not directly assess hydration status or the effectiveness of fluid resuscitation. Passing formed stools, decrease in stool frequency, and absence of perianal burning may be positive outcomes in diarrhea management, but they do not specifically indicate successful fluid resuscitation.
The nurse is aware that the shift of body fluids associated with the intravenous administration of albumin occurs by the process of:
- A. Filtration
- B. Osmosis
- C. Diffusion
- D. Active Transport
Correct Answer: A
Rationale: The correct answer is A: Filtration. Albumin is a large protein molecule that cannot pass through the semipermeable membrane of blood vessels. Therefore, the shift of body fluids associated with intravenous albumin administration occurs through the process of filtration, where fluid moves across the membrane due to a pressure difference. Osmosis (B) involves the movement of water across a semipermeable membrane, which is not the case for albumin. Diffusion (C) is the movement of molecules from an area of high concentration to low concentration, which is not how albumin moves. Active transport (D) requires energy to move substances against a concentration gradient, which is not the mechanism for albumin movement in the body.