A nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include:

Correct Answer: A

Rationale: The correct answer is A: Sunken eyeballs and poor skin turgor. In the early stages of dehydration, the body loses water and the skin loses elasticity, leading to poor skin turgor. Sunken eyeballs are also a common sign of dehydration due to fluid loss. Thirst or confusion (Choice B) are more common in moderate to severe dehydration. Increased heart rate with hypotension (Choice C) typically occurs in moderate to severe dehydration. Coma or seizures (Choice D) are signs of severe dehydration and would not be seen in the early stages. Therefore, A is the correct choice for early manifestations of dehydration.

Correct Answer: C

Rationale: The correct answer is C) The catheter will provide information about your left ventricular function. Rationale: Insertion of a pulmonary artery catheter allows for the measurement of various hemodynamic parameters, including pulmonary artery pressure, pulmonary capillary wedge pressure, and cardiac output. Specifically, the catheter can provide valuable information about the left ventricular function by measuring the pulmonary capillary wedge pressure, which reflects the left atrial pressure and indirectly the left ventricular end-diastolic pressure. Monitoring left ventricular function is crucial in assessing cardiac performance and guiding treatment in patients with cardiovascular conditions. Explanation of Incorrect Options: A) The catheter will assist in directly monitoring your arterial pressure - While a pulmonary artery catheter can provide information about arterial pressure indirectly, its primary role is in assessing cardiac function rather than arterial pressure monitoring. B) The catheter will provide information about your cardiac output - This statement is partially correct, as the catheter can indeed provide information about cardiac output. However, the specific focus of a pulmonary artery catheter is more on assessing ventricular function rather than solely cardiac output. D) The catheter will provide information about your cardiac index - While the cardiac index can be calculated based on cardiac output and body surface area, the primary purpose of a pulmonary artery catheter is to assess hemodynamic parameters related to cardiac function, including left ventricular function. Educational Context: Understanding the indications and implications of pulmonary artery catheterization is essential for nurses caring for patients with cardiovascular disorders. Preprocedural teaching should include explaining the purpose of the catheter, the parameters it can measure, and the importance of monitoring left ventricular function in assessing cardiac status. By providing comprehensive education, nurses can empower patients to participate in their care and better understand the rationale behind specific interventions for their condition.

Correct Answer: A

Rationale: In this scenario, the correct action to take first when a patient receives a new order for transesophageal echocardiography (TEE) is to make the patient NPO (nothing by mouth). This is crucial because TEE is typically performed under sedation, and having food or liquids in the stomach can increase the risk of aspiration during the procedure. Teaching the patient about the procedure (Option B) is important but not the first priority. Ensuring the patient's safety during the procedure takes precedence over education at this immediate moment. Attaching the patient to a cardiac monitor (Option C) is also important for monitoring the patient's heart rhythm during the procedure, but it can be done after ensuring the patient is NPO. Starting an intravenous line (Option D) may be necessary for administering sedation during the TEE, but it should be done after ensuring the patient is NPO to minimize the risk of aspiration. In an educational context, understanding the priority of actions in patient care is vital for healthcare professionals to provide safe and effective care. Prioritizing tasks based on patient safety and procedure requirements is a fundamental aspect of nursing practice.

Correct Answer: C

Rationale: The correct answer is C) Cuff width appropriate for the diameter of the client's arm. This is the correct choice because using a cuff with the appropriate width for the diameter of the client's arm is crucial for obtaining an accurate blood pressure measurement. If the cuff is too narrow, it can lead to falsely elevated readings, while a cuff that is too wide can result in falsely low readings. Option A) is incorrect because while a cuff appropriate for continuous bedside monitoring is important for certain situations, the width of the cuff is essential for accurate BP assessment. Option B) is incorrect as well because while it is important to have a cuff suitable for assessing BP during position changes, the width of the cuff remains a critical factor in obtaining accurate measurements. Option D) is incorrect as a cuff width greater than the diameter of the client's arm can lead to inaccurate readings due to excess space between the cuff and the arm. In an educational context, it is vital for nurses to understand the significance of selecting the right cuff width for blood pressure assessment to ensure accurate readings and provide optimal patient care. Proper training and knowledge in this area can help prevent errors in BP measurement and contribute to better patient outcomes.

Correct Answer: B

Rationale: The correct answer is B) To interfere with platelet aggregation. Administering non-narcotic analgesics to a client with thrombophlebitis helps to reduce pain and inflammation associated with the condition. Non-narcotic analgesics, such as NSAIDs, work by inhibiting the aggregation of platelets, which play a crucial role in the formation of blood clots. By interfering with platelet aggregation, these medications help prevent the formation of clots in the affected vein, reducing the risk of complications such as deep vein thrombosis or pulmonary embolism. Option A) To inhibit prostaglandin is incorrect because while prostaglandins are involved in the inflammatory response and pain sensation, they are not the primary target for non-narcotic analgesics in the context of thrombophlebitis. Option C) Release of endorphins is incorrect as endorphins are the body's natural painkillers and are not directly related to the mechanism of action of non-narcotic analgesics in this scenario. Option D) Release of cellular chemicals is a vague and non-specific option that does not directly address the rationale behind administering non-narcotic analgesics in thrombophlebitis. Educationally, understanding the rationale for using non-narcotic analgesics in thrombophlebitis is crucial for nurses to provide effective pain management and prevent complications associated with clot formation. By grasping the mechanism of action of these medications, nurses can make informed decisions and provide safe and holistic care to their patients with thrombophlebitis.