A 16 y.o. girl is diagnosed with genital herpes. She is tearful and as she asks what she can do to prevent complications of the disease. Based on the data provided, which nursing diagnosis is appropriate for her plan of care?

Correct Answer: A

Rationale: Given that the 16-year-old girl has been diagnosed with genital herpes and is concerned about preventing complications of the disease, the most appropriate nursing diagnosis would be "Risk for transmission of infection." Genital herpes is a highly contagious sexually transmitted infection, and individuals with the infection can transmit it to their partners through sexual contact. Therefore, it is crucial to educate the girl on ways to prevent the transmission of the infection to others. By addressing this nursing diagnosis, the healthcare team can provide guidance on safer sexual practices, including the use of condoms, abstinence during outbreaks, and communication with partners to prevent the spread of the infection. This nursing diagnosis focuses on promoting the girl's health and preventing further complications related to the transmission of genital herpes.

Correct Answer: C

Rationale: Nursing assessment for a patient with metabolic alkalosis includes evaluation of laboratory data for hypocalcemia, hypokalemia, and hypoxemia as these are commonly associated with this acid-base imbalance. Hypoglycemia, on the other hand, is not typically linked with metabolic alkalosis and is not commonly assessed in this context. Therefore, hypoglycemia would not be a key focus of nursing assessment in a patient with metabolic alkalosis.

Correct Answer: A

Rationale: Suctioning a tracheostomy tube is a procedure that requires proper technique to prevent complications. Hyperventilating James with 100% oxygen before and after suctioning indicates that Wilma is committing an error. The correct approach is to provide pre-oxygenation with 100% oxygen for at least two minutes before suctioning to prevent hypoxemia. However, hyperventilation with 100% oxygen can lead to oxygen toxicity, which can be harmful to the patient. The other options, instilling normal saline to loosen secretions, applying suction during catheter withdrawal, and suctioning the client every hour are appropriate techniques when performing tracheostomy tube suctioning.

Correct Answer: C

Rationale: The patient with kidney failure is most at risk for fluid volume overload because the kidneys are responsible for regulating fluid balance in the body. In kidney failure, the kidneys are unable to effectively filter and excrete excess fluids, leading to an accumulation of fluid in the body. This can result in fluid volume overload, which can be dangerous and lead to complications such as pulmonary edema, congestive heart failure, and hypertension. It is important to monitor this patient closely for signs and symptoms of fluid overload and manage their fluid intake carefully.

Correct Answer: C

Rationale: Puffiness at the site is the symptom that most likely indicates that an infusion is infiltrated. Infiltration occurs when the IV fluid leaks into the surrounding tissues instead of entering the vein. This can lead to swelling and puffiness at the site as the fluid accumulates in the tissue. Redness, pain, and exudate at the site are also common signs of infiltration, but puffiness specifically points towards the fluid accumulating outside the vein. If infiltration is suspected, it is important to stop the infusion, remove the IV catheter, and apply appropriate treatment based on the severity of the infiltration.