A) Heart rate 60/min: A heart rate of 60 beats per minute is on the lower end of the normal range. While bradycardia can be concerning, it does not indicate the need for an increase in dopamine dosage specifically. The primary goal of dopamine administration in hypovolemic shock is to improve perfusion and blood pressure, rather than solely addressing heart rate.

B) Respiratory rate 14/min: A respiratory rate of 14 breaths per minute is within the normal range for adults. This finding suggests that the client is not experiencing respiratory distress and does not warrant an increase in the dopamine dosage. The focus should be on hemodynamic parameters rather than respiratory rate in this context.

C) Oxygen saturation 95%: An oxygen saturation of 95% is considered acceptable and indicates adequate oxygenation. While maintaining oxygen saturation is important, this finding does not directly reflect the effectiveness of dopamine in improving hemodynamics. Therefore, it does not indicate the need for a dosage increase.

D) Blood pressure 90/50 mm Hg: A blood pressure reading of 90/50 mm Hg indicates hypotension and poor perfusion, which is a significant concern in a client with hypovolemic shock. An increase in dopamine dosage is warranted in this situation, as dopamine is administered to enhance cardiac output and improve blood pressure. Therefore, this finding strongly indicates the need to adjust the medication to ensure adequate hemodynamic support.

A) Serosanguineous drainage: While serosanguineous drainage can be expected after surgery, it is typically not alarming unless it significantly increases or changes in character. This finding alone does not indicate an immediate complication that requires urgent attention, making it a lower priority to report compared to other findings.

B) Client report of incisional pain: Postoperative pain is common and expected after a complete thyroidectomy. While the nurse should assess and manage the pain appropriately, this symptom is not unusual and does not signal a critical issue that would necessitate immediate reporting to the healthcare provider.

C) Client report of nausea: Nausea can occur after surgery due to anesthesia or medications. Although it should be addressed and managed, it is not a life-threatening complication. Therefore, this finding does not take priority over other more concerning symptoms.

D) Muscle twitching: Muscle twitching in a postoperative thyroidectomy patient may indicate hypocalcemia, a possible complication due to potential damage to the parathyroid glands during surgery. This condition can lead to severe complications if not addressed promptly, including tetany or seizures. Given the potential seriousness of this finding, it is critical for the nurse to report it to the healthcare provider immediately to ensure appropriate evaluation and intervention.

A) Avoid administering IV pain medication: While caution is warranted when administering IV medications to a client with petechiae, particularly if thrombocytopenia is suspected, avoiding pain management is not the appropriate action. Pain relief is crucial for the client’s comfort, and IV medications can be safely administered with proper precautions.

B) Determine the client's blood type: Knowing the client's blood type is important for transfusion purposes, especially if there is significant bleeding. However, this action is not the immediate priority in response to the observation of petechiae. The presence of petechiae is more directly related to bleeding risk rather than blood type.

C) Implement airborne precautions: Airborne precautions are necessary for certain infections (e.g., tuberculosis), but they are not indicated for the management of petechiae related to chronic lymphocytic leukemia. The presence of petechiae does not suggest an airborne infection; thus, this action does not address the immediate concern.

D) Institute bleeding precautions: Petechiae indicate a potential for bleeding due to thrombocytopenia, which is common in clients with chronic lymphocytic leukemia. Instituting bleeding precautions, such as using a soft toothbrush, avoiding invasive procedures, and monitoring for additional signs of bleeding, is crucial to prevent serious complications. Therefore, this action is the most appropriate and immediate response.

A) "Clean the spacer daily with cold water": While it is important to clean the spacer regularly to prevent bacterial growth, the recommendation is usually to clean it weekly with warm, soapy water rather than daily with cold water. This detail is essential for effective use but not the most critical point during initial teaching.

B) "Hold your breath for 10 seconds once you inhale": This statement is key to ensuring effective medication delivery. Holding the breath for about 10 seconds allows the medication to settle in the lungs, maximizing its therapeutic effects. This information is crucial for the client to understand the proper technique for using the inhaler with a spacer.

C) "Wait 30 seconds between puffs": While it is advisable to wait for a brief period between puffs to allow the first dose to be effective, the recommended wait time is generally around 1 minute, particularly if using a different medication or if instructed by the healthcare provider. Therefore, stating 30 seconds may be misleading.

D) "The spacer should make a whistling sound as you inhale": A whistling sound during inhalation may indicate that the spacer is being used incorrectly or that the client is inhaling too forcefully. The absence of a whistling sound is often a sign of proper technique. Therefore, this statement is misleading and not appropriate teaching for effective inhaler use.

A) Respiratory rate 10/min: A respiratory rate of 10 breaths per minute indicates bradypnea, which may be concerning. However, this finding is not directly associated with metoprolol. Metoprolol primarily affects heart rate and blood pressure, making this less relevant in identifying an adverse effect of the medication.

B) Blood pressure 138/76 mm Hg: This blood pressure reading is within the normal range for most individuals. While metoprolol can lower blood pressure, this value does not indicate an adverse effect, as it shows adequate control rather than a concerning reaction.

C) Heart rate 48/min: A heart rate of 48 beats per minute indicates bradycardia, a known adverse effect of beta-blockers like metoprolol. In patients with heart failure, this can lead to insufficient cardiac output and may require intervention. Thus, this finding is critical and should be addressed immediately.

D) Temperature 36.3° C (97.3° F): This temperature is within the normal range and does not indicate an adverse effect related to metoprolol. While monitoring temperature is important, it is not a direct concern regarding the use of this medication.

A)"Iwilltrytolimitfoodsthatcontainsalt.":Limitingsaltintakeisimportantformanagingheartfailurebutdoesn'tspecificallyaddresstheadverseeffectsoffurosemide.Thisdiureticcancauseelectrolyteimbalances,butsaltrestrictionismorerelatedtooverallheartfailuremanagement.

B)"I'mgoingtoincludemorecantaloupeinmydiet.":Furosemidecancausepotassiumdepletion,andcantaloupeishighinpotassium.Increasingpotassium-richfoodsinthediethelpscounteractthisadverseeffect,indicatingtheclientunderstandstheneedtomaintainelectrolytebalance.

C)"IwillcheckmypulsebeforeItakethemedication.":Whilemonitoringheartratecanbeusefulinmanagingheartconditions,itisnotspecifictotheprimaryadverseeffectsoffurosemide.Thekeyconcernwiththismedicationisitsimpactonelectrolytesandfluidbalance.

D)"I'llcheckmybloodpressuresoitdoesn'tgettoohigh.":Furosemidetypicallylowersbloodpressure,sotheconcernwouldbehypotension(lowbloodpressure)ratherthanhypertension(highbloodpressure).Thisstatementdoesn’treflectanunderstandingoffurosemide’sprimaryadverseeffects.

A) Spironolactone: Spironolactone is a potassium-sparing diuretic often used in heart failure and hypertension management. It is not indicated for allergic reactions or hives and does not address the symptoms caused by IV contrast dye.

B) Metoclopramide: Metoclopramide is an antiemetic medication used to treat nausea and vomiting. It is not effective for treating allergic reactions or urticaria, so this option is not appropriate in this context.

C) Diphenhydramine: Diphenhydramine is an antihistamine that is commonly used to treat allergic reactions, including hives and urticaria. Administering diphenhydramine will help alleviate the symptoms related to the adverse reaction to the IV contrast dye, making it the most appropriate medication to administer in this situation.

D) Desmopressin: Desmopressin is used to treat conditions such as diabetes insipidus and certain bleeding disorders. It has no role in treating allergic reactions or hives, making it an inappropriate choice for this scenario.

A) "I will store prefilled syringes in the refrigerator with the needle pointed downward.": While prefilled syringes should be stored in the refrigerator, they should actually be stored with the needle pointing upward. This prevents the insulin from settling at the needle end and ensures that the insulin is readily available for injection. This statement reflects a misunderstanding of proper storage techniques.

B) "I will shake the NPH vial vigorously before drawing up the insulin.": NPH insulin should be gently rolled between the palms rather than shaken vigorously. Shaking can cause air bubbles and damage the insulin. This statement indicates a lack of understanding of the proper technique for preparing NPH insulin.

C) "I will insert the needle at a 15-degree angle.": The correct angle for injecting insulin is typically 90 degrees (or 45 degrees for thin clients), not 15 degrees. This statement shows a misunderstanding of proper injection technique.

D) "I will draw up the regular insulin into the syringe first.": This statement indicates an understanding of the proper technique for mixing insulins. When using both regular and NPH insulins, the regular insulin should always be drawn up first to prevent contamination of the short-acting insulin with the longer-acting insulin. This response reflects correct knowledge regarding insulin administration.

A) "Your breathing pattern causes this.": This statement accurately explains the phenomenon known as "tidaling." The rise and fall of fluid in the water-seal chamber is a normal response to the client’s breathing. As the client inhales, the negative pressure in the pleural space increases, causing the fluid level to rise, and it falls during exhalation. This indicates that the chest tube is functioning properly.

B) "This indicates a possible air leak.": An air leak would typically manifest as continuous bubbling in the water-seal chamber, not as tidaling. Tidaling is a normal finding, so this statement is misleading and does not accurately describe the situation.

C) "This means your lung is fully re-expanded.": While tidaling can be a sign of lung re-expansion, it does not definitively indicate that the lung is fully re-expanded. The presence of tidaling alone does not confirm complete re-expansion of the lung.

D) "Suction pressure that is too high causes this.": Suction pressure relates to the amount of suction applied to the drainage system, but it does not cause the normal rise and fall of fluid in the water-seal chamber. This statement is incorrect in the context of explaining the observed phenomenon.

A) Decorticate posturing: This is a more severe and late sign of increased intracranial pressure and indicates significant neurological impairment. It is not typically seen as an early manifestation.

B) Restlessness: Restlessness is often one of the earliest signs of increased intracranial pressure. It can indicate changes in consciousness and may be the first observable change in a client's behavior as ICP begins to rise.

C) Projectile vomiting: This is usually a later sign of increased ICP and may occur as pressure continues to increase. It suggests significant involvement of the brain and is not an early manifestation.

D) Papilledema: While papilledema (swelling of the optic nerve head) can occur with increased ICP, it often takes time to develop and is not an immediate or early sign. It typically appears after sustained elevated ICP levels.

A) Obtain the client's vital signs: While obtaining vital signs is important after a seizure, it is not the immediate priority during the seizure event. The focus should be on ensuring the client's safety.

B) Lower the client to the floor: Lowering the client to the floor can be a helpful action if the client is standing, but it is not the first step. If the client is already on the floor, this action may not be necessary.

C) Clear items from the client's surrounding area: This is the first action the nurse should take. Clearing the area helps prevent injury to the client during the seizure, ensuring that no objects could potentially cause harm. Safety is the immediate priority during a seizure.

D) Loosen the client's restrictive clothing: While loosening restrictive clothing can be beneficial, it is a secondary action. The primary concern during a seizure is to ensure the client's immediate safety by clearing the surrounding area.

A) Blistering at the site: Blistering is typically associated with partial-thickness burns rather than full-thickness burns. Full-thickness burns destroy both the epidermis and dermis, which usually do not present with blisters.

B) Epithelialization at the site: Epithelialization is a healing process that occurs after the burn site begins to heal. Since this client has sustained major full-thickness burns only 12 hours ago, epithelialization is not expected at this early stage.

C) Edema at the site: Edema is expected in the early stages following a major burn injury due to the inflammatory response and fluid shift that occurs. This finding aligns with the body's response to trauma and is common within the first 24 hours after a burn.

D) Severe pain at the site: Full-thickness burns typically have less pain at the site compared to partial-thickness burns because the nerve endings in the skin are destroyed. While there may be pain in surrounding areas or in partial-thickness areas, the full-thickness burn itself is often painless.

A) Epinephrine: Epinephrine is primarily used in emergencies for conditions such as anaphylaxis or cardiac arrest. It would not be indicated for managing thirst or urinary output

in this context.

B) Desmopressin: This medication is a synthetic vasopressin analog used to treat diabetes insipidus, which can result from brain injuries affecting the hypothalamus or pituitary gland. Given the client's significant urinary output of 4,000 mL, which suggests possible diabetes insipidus, desmopressin is the most appropriate medication to address the excessive urination and thirst.

C) Nitroprusside: Nitroprusside is a potent vasodilator used to manage acute hypertension. It is not relevant to the symptoms described and would not help in managing thirst or urinary output issues.

D) Furosemide: Furosemide is a diuretic that would increase urinary output rather than decrease it. Since the client is already experiencing high urinary output, furosemide would not be appropriate.

A) Generalized abdominal pain: While abdominal pain can occur with peritonitis, it is not always the earliest indication. Pain may develop after other symptoms become apparent, making it less specific as an initial sign.

B) Fever: Fever is a common symptom of infection, including peritonitis. However, it can also occur in various other conditions and may not be the first noticeable symptom, especially if the infection is localized.

C) Cloudy effluent: Cloudy or turbid dialysate effluent is often the earliest and most specific indication of peritonitis in patients undergoing peritoneal dialysis. This change in the appearance of the effluent suggests an infection, and the presence of cloudy fluid should prompt further evaluation for peritonitis.

D) Increased heart rate: An increased heart rate can be a response to various conditions, including infection, but it is not specific to peritonitis and may not be the earliest sign.

A) Check settings of the CPM machine every 12 hr: This is not frequent enough. The nurse should check the settings of the CPM machine more regularly, typically before each use or every few hours, to ensure the settings are appropriate for the client's therapy.

B) Increase the range of motion rapidly when the CPM machine is used intermittently: This approach is not safe. The range of motion should be increased gradually based on the healthcare provider's orders and the client's tolerance to avoid injury or discomfort.

C) Store the CPM machine on the floor when not in use: Storing the CPM machine on the floor can pose safety hazards, such as tripping or damage to the machine. It should be stored in a safe, designated area when not in use.

D) Turn the CPM machine off while the client is eating: This is an appropriate action. It allows the client to eat comfortably and without obstruction, ensuring they can focus on eating without the machine interfering. Once the client has finished eating, the CPM machine can be turned back on to continue therapy.

A) Diuretic: Diuretics are not typically indicated following an ischemic stroke unless there are specific comorbid conditions, such as heart failure or hypertension, that warrant their use. They do not address the primary needs of stroke management.

B) Anticonvulsant: While some stroke patients may require anticonvulsants if they experience seizures, this is not a standard therapy for all ischemic stroke patients upon discharge. The primary focus after an ischemic stroke is often on preventing future strokes rather than seizure control.

C) Opioid analgesic: Opioids are generally not indicated for stroke management and are not a standard part of discharge therapy. Pain management is important, but other medications are prioritized for stroke prevention and rehabilitation.

D) Antithrombotic: Antithrombotic therapy, which includes antiplatelet agents (like aspirin) or anticoagulants, is crucial for preventing further ischemic events. This type of pharmacologic therapy is typically prescribed for patients post-ischemic stroke to reduce the risk of subsequent strokes.

Diphenhydramine: This is an antihistamine primarily used to treat allergies and as a sedative. It is not indicated for reversing opioid-induced respiratory depression and could potentially worsen the sedation.

Flumazenil: This medication is a benzodiazepine antagonist and is used to reverse the effects of benzodiazepines. It is not effective for opioid overdose or respiratory depression caused by morphine.

Naloxone: Naloxone is an opioid antagonist used to reverse the effects of opioid overdose, including respiratory depression. In cases of opioid-induced respiratory depression, naloxone is the appropriate medication to administer to restore normal respiratory function.

Calcium gluconate: This medication is used for conditions such as hypocalcemia or magnesium toxicity, but it is not relevant for opioid overdose or respiratory depression.

A) Remove one of the weights: This is the appropriate action. If the weights are resting on the floor, it indicates that the traction is ineffective, and removing one weight may be necessary to restore proper traction. However, the nurse should first verify the prescribed amount of weight with the healthcare provider before making adjustments.

B) Pull the client up in bed: While it may be necessary to reposition the client, pulling them up in bed does not address the issue of the weights resting on the floor and could potentially cause discomfort or injury.

C) Increase the elevation of the affected extremity: While elevating the extremity may be beneficial for swelling or comfort, it does not resolve the issue of ineffective traction caused by the weights on the floor.

D) Tie knots in the ropes near the pulleys to shorten them: This action is inappropriate. Tying knots in the ropes could interfere with the proper function of the traction system and is not a safe or effective solution to the problem.

A) Pain level: While assessing pain is important, it is not the immediate priority in the post-anesthesia care unit (PACU). Pain management can be addressed once the client's vital signs and respiratory status are stable.

B) Surgical site: Evaluating the surgical site is necessary to check for complications such as bleeding or infection, but it comes after ensuring the client’s vital functions, particularly their breathing, are stable.

C) Level of consciousness: Assessing the level of consciousness is essential for determining neurological status. However, it is secondary to ensuring the airway and breathing are adequate, as these are critical for survival.

D) Respiratory status: This is the priority assessment in the PACU. Following anesthesia, clients are at significant risk for respiratory complications, including hypoventilation or airway obstruction. Ensuring that the client is breathing adequately and that their airway is clear is the most critical assessment for immediate safety.

A) Elevation in blood pressure: An elevation in blood pressure is not an indicator of the effectiveness of furosemide. In fact, effective diuresis would typically lead to a reduction in blood pressure, especially in cases of pulmonary edema related to heart failure.

B) Respiratory rate of 24/min: A respiratory rate of 24/min indicates tachypnea, which is often associated with respiratory distress or ongoing pulmonary congestion. This finding does not suggest that the furosemide is effective; instead, it may indicate that further intervention is needed.

C) Adventitious breath sounds: The presence of adventitious breath sounds, such as wheezing or crackles, suggests ongoing fluid accumulation in the lungs and is not an indicator of effective diuresis. Effective treatment should lead to clearer breath sounds as fluid is removed.

D) Weight loss of 1.8 kg (4 lb) in the past 24 hr: This finding is a strong indicator of the effectiveness of furosemide. A significant weight loss, especially in a client with pulmonary edema, reflects a reduction in fluid overload. Since furosemide works by promoting diuresis, this weight loss suggests that the medication is effectively reducing excess fluid in the body.

A) Monitor the client's vital signs once every hour: After a cardiac catheterization, it is crucial to monitor vital signs more frequently than every hour. The nurse should assess vital signs every 15 minutes for the first hour, then every 30 minutes for the next two hours, and

then according to the facility's protocol, to quickly identify any complications.

B) Elevate the head of the client's bed to a 45° angle: Elevating the head of the bed to a 45° angle is generally not recommended immediately following cardiac catheterization through the femoral artery. The client should remain flat or with the head elevated no more than 30 degrees to reduce the risk of bleeding from the access site.

C) Instruct the client not to bend the affected leg: This is the most appropriate action. Keeping the affected leg straight is essential to prevent complications such as bleeding or hematoma formation at the catheter insertion site. The client should be instructed to avoid bending or flexing the leg for a specified period, usually several hours post-procedure.

D) Restrict the client's fluid intake: Restricting fluid intake is not necessary after cardiac catheterization. In fact, adequate hydration is often encouraged to help flush the contrast dye from the system and maintain kidney function, provided there are no contraindications.

A) Chronic infections of the middle ear: Chronic middle ear infections can lead to damage of the structures within the ear, resulting in conductive hearing loss. This is a significant risk factor for hearing loss, particularly in children and young adults.

B) Use of a loop diuretic: Loop diuretics, such as furosemide, can be ototoxic, especially at high doses or when used in conjunction with other ototoxic medications. This can result in hearing loss, making this a relevant risk factor to discuss.

C) Perforation of the eardrum: A perforated eardrum can lead to conductive hearing loss and increase the risk of infections, which may further compromise hearing. It is essential to include this in the discussion of risk factors for hearing loss.

D) Born with a high birth weight: High birth weight alone is not a recognized risk factor for hearing loss. While certain conditions associated with high birth weight may impact hearing, it is not a direct factor.

E) Frequent exposure to low-volume noise: Low-volume noise exposure is typically not a risk factor for hearing loss. It is the exposure to loud noise over time that poses a greater risk. Therefore, this factor should not be included in the teaching.

A) Glycosylated hemoglobin level: The glycosylated hemoglobin (HbA1c) level is the most reliable indicator of long-term glycemic control in clients with diabetes mellitus. It reflects average blood glucose levels over the past 2 to 3 months, allowing healthcare providers to assess how well the treatment plan is working over time.

B) Oral glucose tolerance test results: The oral glucose tolerance test (OGTT) is primarily used for diagnosing diabetes rather than monitoring long-term control. It assesses how well the body processes glucose but does not provide an ongoing measure of glycemic control.

C) Postprandial blood glucose level: While monitoring postprandial blood glucose (the blood glucose level after meals) is important for managing daily glucose levels, it does not give a long-term perspective on glycemic control. This measurement can fluctuate significantly based on diet and activity levels.

D) Fasting blood glucose level: The fasting blood glucose level is useful for assessing daily glucose control, but it does not provide a comprehensive view of long-term glycemic management over months like the HbA1c level does.

A) Chloride level: Chloride levels are generally not affected by gout. While electrolyte imbalances can occur in various conditions, they are not specifically associated with acute gout attacks.

B) Uric acid: An increase in uric acid levels is expected in clients with acute gout. Gout is caused by the accumulation of uric acid crystals in the joints, leading to inflammation and pain. Monitoring uric acid levels is crucial for diagnosing and managing this condition.

C) Creatinine kinase: Creatinine kinase levels are typically elevated in conditions related to muscle damage or injury, rather than gout. While some muscle soreness may occur during a gout flare, it is not a primary indicator for this condition.

D) Intrinsic factor: Intrinsic factor is related to vitamin B12 absorption and is not relevant to gout. It is primarily associated with conditions like pernicious anemia rather than gout or uric acid metabolism.

A) Instruct the client to expect tingling in their extremities: Tingling in the extremities is not a common or expected outcome of a lumbar puncture. While some clients may experience mild discomfort, tingling could indicate nerve irritation or other complications that should be assessed.

B) Limit the client's fluid intake: After a lumbar puncture, clients are typically encouraged to increase their fluid intake to help replenish cerebrospinal fluid (CSF) and reduce the risk of headaches. Limiting fluid intake is not appropriate.

C) Measure blood glucose every 2 hr: Routine blood glucose monitoring is not indicated immediately following a lumbar puncture unless there is a specific concern or reason to do so. This action does not directly relate to the care needed post-procedure.

D) Instruct the client to lie flat: Lying flat is often recommended after a lumbar puncture to reduce the risk of post-puncture headache, which can occur due to changes in CSF pressure. This position helps promote healing and minimizes discomfort.