Correct Answer: B

Rationale: A serum albumin level of 3 g/dL is indicative of poor nutrition, a common factor in the development of pressure ulcers. The Braden scale assesses the risk of developing pressure ulcers but does not reflect the client's medical history. Hemoglobin level is more related to oxygen-carrying capacity rather than pressure ulcer development. The Norton scale evaluates risk for developing pressure ulcers but is not typically part of a client's medical history.

Correct Answer: B

Rationale: In conscious clients with hypoglycemia, the most appropriate action is to provide a rapidly absorbed carbohydrate source like fruit juice to raise blood glucose levels quickly. Administering glucagon intramuscularly (IM) is usually reserved for unconscious clients or those who are unable to take oral glucose. Providing peanut butter or water would not rapidly address the hypoglycemic state as fruit juice would.

Correct Answer: C

Rationale: In the early stages of hypovolemic shock, the body initiates compensatory mechanisms to maintain perfusion. One of these mechanisms is an increased respiratory rate to improve oxygen delivery. This helps to offset the decreased circulating blood volume. A heart rate of 60/min (choice
A) is not expected in hypovolemic shock; instead, tachycardia is a common finding due to the body's attempt to maintain cardiac output. Increased urinary output (choice
B) is not typically seen in hypovolemic shock as the body tries to conserve fluid. Hypothermia (choice
D) is usually a late sign of shock when the body's compensatory mechanisms are failing, and perfusion is severely compromised.

Correct Answer: C

Rationale: Increased urine output is a positive sign that the IV fluids are effectively treating dehydration. Tachycardia (choice
A) and hypotension (choice
B) are signs of dehydration and would not be considered positive responses to therapy. Diarrhea (choice
D) can worsen dehydration and is not a positive response to IV fluid therapy.

Correct Answer: B

Rationale: The correct answer is to check for air leaks and ensure the proper functioning of the chest tube. This action is crucial post-op to prevent complications such as pneumothorax or hemothorax. Clamping the chest tube every 2 hours (
Choice
A) is incorrect as it can lead to a buildup of pressure within the chest, risking complications. Encouraging deep breathing and coughing every 2 hours (
Choice
C) is important for respiratory hygiene but not the priority over ensuring the chest tube's proper function. Encouraging frequent coughing to clear secretions (
Choice
D) is not the priority when assessing a chest tube post-op; ensuring the chest tube's integrity and function take precedence.