A client with ascites has a paracentesis, and 1500 ml of fluid is removed. Immediately following the procedure it is most important for the nurse to observe for:

Correct Answer: A

Rationale: The correct answer is A: A rapid, thready pulse. After paracentesis, rapid removal of ascitic fluid can lead to a decrease in intravascular volume, causing hypovolemia and subsequent compensatory mechanisms like tachycardia (rapid pulse). This is a crucial sign that the nurse should monitor for early detection of hypovolemia. B: Decreased peristalsis is not directly related to paracentesis and is not an immediate concern post-procedure. C: Respiratory congestion is not a common complication of paracentesis and is not the most immediate concern. D: An increased temperature is not a typical response to paracentesis and is not a priority observation post-procedure.

Correct Answer: B

Rationale: The correct answer is B because the nurse should always prioritize communication with the patient, especially when the patient is alert and oriented. Speaking only to the patient's daughter could undermine the patient's autonomy and right to be involved in their care. It is important for the nurse to directly address the patient to gather accurate information and ensure patient-centered care. Making eye contact (A), leaning forward (C), and nodding periodically (D) are all appropriate communication techniques that show attentiveness and engagement with the patient, which are crucial in building rapport and trust.

Correct Answer: A

Rationale: The correct answer is A: White patches on the tonsils. Group A streptococci infection commonly presents with exudative tonsillitis, characterized by the presence of white patches or pus on the tonsils. This is due to the inflammatory response triggered by the bacteria. Hypertrophied tonsils (B), hemorrhage in the tonsils (C), and bleeding in the tonsils (D) are less likely to be visual signs of a streptococcal infection and are more indicative of other conditions or complications. Therefore, white patches on the tonsils are the most specific visual sign associated with group A streptococci tonsillar infection.

Correct Answer: B

Rationale: The correct answer is B because the nurse should primarily communicate with the patient, not just the daughter. This ensures patient-centered care and respects the patient's autonomy. Speaking only to the daughter may undermine the patient's dignity and may lead to incomplete information gathering. Choices A, C, and D are incorrect as they are appropriate nursing communication techniques that facilitate rapport-building and active listening with the patient. Making eye contact, leaning forward, and nodding are all positive non-verbal cues that show engagement and attentiveness to the patient, promoting effective communication and building trust.

Correct Answer: C

Rationale: Step-by-step rationale for why choice C is correct: 1. The lab value of K at 3.2 mEq/L indicates hypokalemia. 2. Digitalis can worsen hypokalemia and lead to toxicity. 3. Avoiding foods rich in potassium will prevent further lowering of potassium levels. 4. This intervention helps prevent potential digitalis toxicity in the client. Summary of why the other choices are incorrect: A. Stopping digitalis therapy abruptly can lead to rebound effects and worsen the condition. B. Trousseau's and Chvostek's signs are not relevant to the client's current lab values. D. While observing for digitalis toxicity is important, addressing the low potassium level is a more immediate concern in this scenario.

Correct Answer: B

Rationale: The correct answer is B: Collect his urine for 12 hours. This instruction is given because the Schilling test involves collecting urine over a specific time period to measure the absorption of vitamin B12. A is incorrect because fasting is not necessary. C is incorrect as enema is not required. D is incorrect as emptying the bladder is not part of the test procedure.

Correct Answer: C

Rationale: Step 1: Mr. Dela Isla had a CVA, indicating the importance of managing his condition long-term. Step 2: Drug compliance is crucial in preventing further strokes and managing existing health issues. Step 3: Proper medication adherence can help control blood pressure, cholesterol, and blood sugar levels. Step 4: Emergency numbers are important but secondary to long-term management. Step 5: Relaxation techniques may be beneficial but not as essential as medication compliance for a CVA patient.

Correct Answer: C

Rationale: The correct answer is C: Serum calcitonin level. Smoking can elevate serum calcitonin levels due to the effect of nicotine. However, an elevated serum calcitonin level is not a general indicator of cancer. Step 1: Understand that smoking can increase serum calcitonin levels. Step 2: Recognize that elevated serum calcitonin levels are not specific to cancer and can be influenced by other factors. Step 3: Differentiate between a marker that is specific to cancer (such as carcinoembryonic antigen) and one that can be affected by smoking but not necessarily indicative of cancer (serum calcitonin). Thus, while smoking can elevate serum calcitonin levels, it is not a reliable indicator of cancer.

Correct Answer: D

Rationale: The correct answer is D because the patient correctly stating names of family members in the room indicates improved cognitive function and memory recall, which are positive signs of progress in resolving confusion. This demonstrates improved orientation and ability to recognize familiar individuals. Choices A and B indicate safety concerns and risk of falls, which are not related to resolving confusion. Choice C indicates pain management and mobility but does not directly reflect improvement in cognitive status.