a. Prothrombin time (PT): Warfarin affects the extrinsic pathway of the coagulation cascade, and PT is the primary diagnostic test used to monitor the therapeutic effect of warfarin. It measures

the time it takes for blood to clot.

b. Platelet count: Platelet count assesses the number of platelets in the blood and is not specifically used to monitor the effect of warfarin.

c. White blood cell count (WBC): WBC count assesses the number of white blood cells and is not specifically used to monitor the effect of warfarin.

d. Activated partial thromboplastin time (aPTT): While aPTT is a valuable test for monitoring the therapeutic effect of heparin, it is not the primary test for warfarin. Warfarin primarily affects the extrinsic pathway, and PT is more appropriate for monitoring its effects.

b. Paralytic ileus: Absence of bowel sounds, abdominal distention, and no passage of flatus are characteristic signs of paralytic ileus, which is a temporary impairment of bowel motility following surgery.

c. Health care-associated Clostridium difficile: Clostridium difficile infection is associated with diarrhea, abdominal pain, and fever. The absence of bowel sounds and abdominal distention is not consistent with C. difficile infection.

d. Fecal impaction: Fecal impaction is characterized by a blockage of hardened stool in the

rectum or colon, leading to difficulty passing stool. It may cause abdominal discomfort, but it does not typically present with the absence of bowel sounds and abdominal distention seen in paralytic ileus.

a. C-reactive protein: This is a marker of inflammation and is not specific to renal function. It is more commonly used to assess inflammation in various conditions.

b. Serum creatinine: Elevated levels of serum creatinine are indicative of impaired renal

function. Creatinine is a waste product that is normally filtered by the kidneys. Increased levels suggest decreased renal filtration.

c. Antinuclear antibody: This test is used to diagnose autoimmune diseases like SLE but does not directly measure renal function.

d. Erythrocyte sedimentation rate: This is a nonspecific marker of inflammation and is not directly related to renal function.

a. Ineffective airway clearance: This is the priority as it addresses the immediate threat to the client's respiratory status. Accumulation of thick, copious secretions can lead to airway

obstruction and respiratory distress.

b. Malnourishment: While important, addressing malnourishment is not an immediate

postoperative priority. The client may receive nutrition through alternative means until normal swallowing function is restored.

c. High risk for infection: Infection is a concern, but ensuring airway clearance takes precedence in the immediate postoperative period.

d. Impaired verbal communication: Verbal communication is important, but it is not as immediate a concern as ensuring the airway is clear to prevent respiratory compromise.

a. Allow the client to take her morning vitamins: This is generally acceptable unless there are specific preoperative instructions regarding medication.

b. Allow the client to keep her tongue stud in: Metallic objects, including tongue studs, are

usually removed before surgery to prevent interference with equipment and to ensure patient safety.

c. Allow the client to keep her hearing aids in: It is important for the client with a hearing

impairment to keep hearing aids in place to facilitate communication and maintain awareness of the environment.

d. Allow the client to consume clear liquids up to the time of surgery: Clear liquids are typically restricted before surgery to prevent aspiration. This action may not align with standard

preoperative fasting guidelines.

a. Serum potassium: Furosemide is a loop diuretic that can lead to potassium loss, potentially causing hypokalemia. Monitoring potassium levels is crucial to prevent complications such as cardiac arrhythmias.

b. Serum amylase: This is not directly related to furosemide therapy. Amylase is an enzyme associated with pancreatic and salivary function.

c. Serum triglyceride: Furosemide does not typically have a direct impact on serum triglyceride levels.

d. Serum cholesterol: Furosemide does not typically have a direct impact on serum cholesterol levels.

a. Hyperactive bowel sounds: Shock is more likely to be associated with decreased bowel sounds rather than hyperactive bowel sounds.

b. Increased urine output: In the early stages of shock, there may be an increase in urine output as the body attempts to compensate. However, as shock progresses, renal perfusion decreases,

leading to decreased urine output.

c. Hypotension: Hypotension is a key indicator of shock. In shock, there is insufficient blood flow to meet the body's oxygen and nutrient needs, resulting in a drop in blood pressure.

d. Bradycardia: Shock typically leads to an increased heart rate (tachycardia) as the body tries to compensate for decreased cardiac output. Bradycardia is not a typical finding in the early stages of shock.

a. Urinary retention: Dark amber, cloudy, and malodorous urine is not typically associated with urinary retention. Urinary retention usually results in a lower-than-normal urine output.

b. Urinary incontinence: Incontinence refers to the inability to control urine flow and does not directly cause changes in urine color, clarity, or odor.

c. Urinary frequency: Increased frequency of urination is not typically associated with dark amber, cloudy, and malodorous urine.

d. Urinary tract infection (UTI): Dark amber, cloudy, and foul-smelling urine are common signs of a urinary tract infection. The infection causes changes in the appearance and odor of urine due to the presence of bacteria and inflammatory cells.

a. Low BP and low pulse rate: In hypovolemic shock, there is a decrease in blood volume,

leading to low blood pressure. However, the body compensates by increasing the heart rate to maintain perfusion to vital organs.

b. Low BP and high pulse rate: This is indicative of hypovolemic shock. The low blood pressure results from decreased blood volume, while the high pulse rate is a compensatory mechanism to maintain cardiac output.

c. High BP and low pulse rate: This combination is not typical of hypovolemic shock. High blood pressure is not expected in the presence of decreased blood volume.

d. High BP and high pulse rate: While a high pulse rate is expected in hypovolemic shock, high blood pressure is not a characteristic finding.

a. Creatinine 0.9 mg/dL: This creatinine level is within the normal range and is not an immediate priority for knee arthroplasty.

b. WBC count 20,000/mm3: An elevated white blood cell count suggests the presence of

infection or inflammation. In the context of knee arthroplasty, infection is a significant concern and requires immediate attention to prevent complications.

c. Potassium 3.8 mEq/L: This potassium level is within the normal range and is not an immediate priority for knee arthroplasty.

d. Hematocrit 40%: This hematocrit level is within the normal range and is not an immediate priority for knee arthroplasty. The elevated WBC count takes precedence as it suggests a

potential infectious process.

a. "This test will inform your provider if you are anemic." Serum creatinine is not used to assess anemia. Anemia is often evaluated through tests like hemoglobin and hematocrit.

b. "This test will inform your provider if you have an infection." Serum creatinine is not a direct indicator of infection. It is primarily used to assess kidney function.

c. "This test will inform your provider if you have a thyroid disorder." Serum creatinine is not

used to evaluate thyroid function. Thyroid function is typically assessed through thyroid function tests.

d. "This test will inform your provider how your kidneys are functioning." This is the correct

response. Serum creatinine is a waste product that is filtered by the kidneys, and elevated levels may indicate impaired renal function.

a. Bradycardia: Atenolol is a beta-blocker that can slow down the heart rate, leading to

bradycardia. Monitoring the client for signs of bradycardia, such as dizziness, fatigue, or fainting, is important.

b. Anemia: Atenolol is not known to cause anemia. Monitoring for anemia is not a specific concern with this medication.

c. Hypokalemia: Atenolol is not associated with causing hypokalemia. However, beta-blockers in general may affect potassium levels indirectly.

d. Neutropenia: Atenolol is not typically associated with causing neutropenia. Monitoring for neutropenia is not a specific concern with this medication.

a. Decreased calcium level: NG tube drainage is more likely to result in hypokalemia (decreased potassium) than hypocalcemia (decreased calcium).

b. Decreased potassium level: NG tube drainage, which contains stomach contents, can lead to loss of potassium. Monitoring for hypokalemia is crucial as it can result in cardiac dysrhythmias.

c. Elevated magnesium level: NG tube drainage is not typically associated with an increase in magnesium levels.

d. Elevated sodium level: NG tube drainage may contribute to sodium loss, leading to hyponatremia, rather than hypernatremia.

a. "Both illnesses begin in the rectum." This statement is not accurate. Ulcerative colitis typically begins in the rectum and progresses proximally, while Crohn's disease can involve any part of the digestive tract.

b. "Both illnesses are inflammatory in nature." This is the correct statement. Both ulcerative colitis and Crohn's disease are inflammatory bowel diseases characterized by chronic

inflammation of the gastrointestinal tract.

c. "Both illnesses manifest fistula formation." Fistula formation is more commonly associated with Crohn's disease, not ulcerative colitis.

d. "Both illnesses result in malabsorption of nutrients." While malabsorption can occur in both conditions, it is generally more associated with Crohn's disease than ulcerative colitis.

a. Provide humidified oxygen: Humidification helps prevent the drying of mucous membranes, making secretions more manageable and less tenacious. This is an acceptable method to thin

secretions in a client with a tracheostomy.

b. Prelubricate the suction catheter tip with sterile saline when suctioning the airway: While lubrication with sterile saline is a common practice during suctioning to reduce trauma to the airway, it does not directly address the tenacity of secretions.

c. Perform chest physiotherapy prior to suctioning: Chest physiotherapy is a technique used to mobilize respiratory secretions, but it may not directly address the tenacity of secretions.

d. Hyperventilate the client with 100% oxygen before suctioning the airway: Hyperventilation with 100% oxygen is not a routine practice and may lead to respiratory alkalosis. Providing

humidified oxygen is a more appropriate approach.

a. Battle's sign: Battle's sign is bruising over the mastoid process and is not a direct manifestation of increased intracranial pressure.

b. Nuchal rigidity: Nuchal rigidity (stiff neck) is associated with irritation of the meninges and is not a specific sign of increased intracranial pressure.

c. Lethargy: Lethargy or altered level of consciousness is a common manifestation of increased intracranial pressure. It can range from mild drowsiness to severe impairment of consciousness.

d. Polyuria: Polyuria is not a typical manifestation of increased intracranial pressure. Increased urine output may be associated with other conditions, such as diabetes or diuretic use.

a. Instruct the client to tilt her head back when she swallows: This action is not recommended, as it increases the risk of aspiration. Tilted head positions can lead to improper bolus control and

swallowing difficulties.

b. Add thickener to fluids: This is an appropriate intervention for a client with dysphagia, as thickened fluids are easier to control during swallowing and reduce the risk of aspiration.

c. Place food on the left side of the client's mouth: This action may not directly address the risk of aspiration associated with dysphagia and left-sided weakness.

d. Serve food at room temperature: While serving food at room temperature may be preferred for some clients, it does not directly address the safety concerns associated with dysphagia and left- sided weakness.

a. Increasing dyspnea: Atelectasis is the collapse of alveoli, leading to decreased lung volume and impaired gas exchange. Dyspnea (difficulty breathing) is a common symptom as the lung's ability to oxygenate the blood is compromised.

b. Dry cough: A dry cough may be present, but it is not specific to atelectasis. It can occur for various reasons postoperatively.

c. Facial flushing: Facial flushing is not a typical finding in atelectasis. It is more commonly associated with conditions such as fever or allergic reactions.

d. Decreasing respiratory rate: Atelectasis can lead to increased respiratory rate as the body tries to compensate for decreased lung function. A decreasing respiratory rate would be less likely in the presence of atelectasis.

a. Blood glucose 150 mg/dL: While elevated blood glucose may be a concern, potassium levels are more critical in the context of acute gastroenteritis, which can lead to fluid and electrolyte

imbalances.

b. Urine specific gravity 1.035: Elevated urine specific gravity indicates concentrated urine and possible dehydration. However, the low potassium level takes precedence as it can lead to

serious cardiac complications.

c. Weight loss of 3% of total body weight: Weight loss is a concern, but the immediate risk of hypokalemia (low potassium) takes priority.

d. Potassium 2.5 mEq/L: This low potassium level is a critical finding that requires prompt attention, as it can lead to cardiac dysrhythmias and other serious complications.

a. "The pain radiates down to my lower back." This statement is not typical of peptic ulcer

disease. Radiation of pain to the lower back may suggest other abdominal or musculoskeletal issues.

b. "I feel so much better after eating." Relief of pain after eating is more indicative of gastric ulcer rather than peptic ulcer disease. Peptic ulcers are often associated with pain that worsens after eating.

c. "My pain is relieved by having a bowel movement." Relief of pain with bowel movements is

not a characteristic finding of peptic ulcer disease. This may suggest other gastrointestinal issues.

d. "The pain is worse after I eat a meal high in fat." This statement is consistent with peptic ulcer disease. High-fat meals stimulate gastric acid secretion, potentially exacerbating the pain

associated with peptic ulcers.

a. A sensory warning that a seizure is imminent: An aura is a subjective sensation or warning that a seizure is about to occur. It can manifest as visual, auditory, or other sensory experiences.

b. A brief loss of consciousness accompanied by staring: This describes an absence seizure, not an aura. Absence seizures are characterized by a brief loss of consciousness without convulsions.

c. A continuous seizure state in which seizures occur in rapid succession: This describes status epilepticus, not an aura. Status epilepticus is a medical emergency characterized by prolonged or rapidly recurring seizures.

d. A period of sleepiness following the seizure during which arousal is difficult: This describes the postictal state, not an aura. The postictal state is a period of altered consciousness or

sleepiness that may follow a seizure.

a. Determine the patency of the tubing: The first action should be to assess for any obstruction or kinks in the tubing. A blockage may be preventing the flow of urine.

b. Notify the provider: While notifying the provider may be necessary, assessing the tubing for patency is a more immediate action.

c. Offer oral fluids: While hydration is important, the priority is to ensure that the urinary catheter is functioning properly.

d. Administer a prescribed analgesic: Pain management is important postoperatively, but the

immediate concern is the lack of urinary output, which requires assessment and intervention to rule out catheter obstruction.

a. Pleural friction rub: Pleural friction rub is a grating sound heard during inspiration and

expiration and is associated with inflammation of the pleura. It is not typically associated with asthma exacerbation.

b. Fine rales: Fine rales (crackles) are usually heard during inspiration and can be associated with conditions such as pneumonia or pulmonary fibrosis. They are not the typical lung sounds in

asthma exacerbation.

c. Rhonchi: Rhonchi are low-pitched wheezes heard during inspiration and expiration. While they can be associated with asthma, expiratory wheezes are more specific to asthma

exacerbation.

d. Expiratory wheeze: Expiratory wheezes are high-pitched, musical sounds heard during

expiration and are characteristic of asthma exacerbation. They result from narrowed airways and increased airway resistance.

a. Complete heart block: Complete heart block would typically present with a regular ventricular rate, but with no association between P waves and QRS complexes.

b. Atrial fibrillation: Atrial fibrillation is characterized by the absence of identifiable P waves and an irregular ventricular rate. The atria fibrillate, leading to chaotic electrical activity and an irregular ventricular response.

c. Sinus tachycardia: Sinus tachycardia is characterized by a regular ventricular rate and identifiable P waves. It is not associated with the absence of P waves.

d. First-degree AV block: First-degree AV block is characterized by a prolonged PR interval, but it does not result in the absence of P waves. The relationship between P waves and QRS

complexes is maintained.

a. Overusing a muscle while jogging: Overuse injuries are more commonly associated with strains, not sprains. Strains involve the muscles or tendons.

b. Twisting a ligament while walking: This is an example of a mechanism that can lead to a sprain. A sprain involves the stretching or tearing of ligaments, which connect bone to bone.

c. Impact injury on a joint from a fall: This is more likely to result in a sprain, as it can cause damage to ligaments.

d. Crush injury to a bone from blunt trauma: This type of injury is more likely to affect bones rather than ligaments or tendons, and it would not be considered a sprain or strain.