A nurse is assisting a client with Hodgkin's lymphoma and has assessed shallow respirations associated with enlarged cervical lymph nodes. What would be the best nursing intervention to assist the client to avoid unnecessary pressure on the trachea and provide for increased lung expansion and improved air exchange?

Correct Answer: C

Rationale: The correct answer is C) Place the client in high Fowler's position. Placing the client in high Fowler's position, with the head of the bed elevated at 90 degrees, helps to reduce pressure on the trachea caused by enlarged cervical lymph nodes in Hodgkin's lymphoma. This position also promotes increased lung expansion and improved air exchange by allowing the diaphragm to descend more freely, thereby enhancing respiratory function. Option A) Encouraging the use of incentive spirometry is a beneficial intervention for promoting deep breathing exercises and improving lung ventilation, but it does not directly address the issue of tracheal pressure caused by enlarged lymph nodes. Option B) Monitoring pulse oximetry and maintaining oxygen saturation at 90% or greater is important for assessing oxygenation status but does not directly alleviate tracheal pressure or improve lung expansion. Option D) Keeping the environment quiet and free of distraction is essential for promoting a restful and healing environment for the client but does not address the physiological need for improved respiratory function in this situation. Educationally, understanding the rationale behind positioning in high Fowler's is crucial for nurses caring for clients with respiratory issues like Hodgkin's lymphoma. It helps students grasp the importance of proper positioning in enhancing respiratory mechanics and ensuring adequate oxygenation for clients with compromised airways. This case underscores the significance of evidence-based nursing interventions in promoting optimal patient outcomes.

Correct Answer: D

Rationale: The correct answer is D) The symptoms of pacemaker malfunction. This teaching need assumes the highest priority because recognizing and understanding the symptoms of pacemaker malfunction is crucial for the patient's safety and well-being. Knowing the signs of malfunction such as dizziness, palpitations, chest pain, or fainting allows the patient to seek immediate medical attention, potentially preventing serious complications or even death. Option A) How to take his pulse daily is important but not as critical as recognizing symptoms of pacemaker malfunction. Monitoring pulse is a routine activity, whereas identifying malfunction symptoms is a matter of urgent concern. Option B) The importance of wearing a medical-alert bracelet is also essential but does not take precedence over knowing the symptoms of malfunction. While the bracelet provides important information in case of emergencies, knowing when to seek help due to malfunction is more pressing. Option C) The positive aspects of life with a pacemaker is a valuable topic for overall patient education but is not as urgent as understanding the signs of malfunction. Patient education on lifestyle adjustments and coping mechanisms can be addressed at a later time once the immediate safety concerns are covered. In an educational context, prioritizing teaching needs based on urgency and potential impact on patient outcomes is crucial in healthcare settings. By focusing on the most critical information first, educators can ensure that patients are equipped with the knowledge needed to manage their health effectively and respond appropriately to emergencies.

Correct Answer: D

Rationale: Rationale: The correct answer is D) Tissue hypoxia due to reduced capacity to carry O2. In all types of anemia, the major physiologic effect that underlies the resulting symptoms is the reduced capacity of the blood to carry oxygen. Anemia is characterized by a decrease in the number of red blood cells or hemoglobin levels, leading to decreased oxygen-carrying capacity. This results in tissue hypoxia, where the body's cells do not receive an adequate supply of oxygen, leading to symptoms such as fatigue, weakness, shortness of breath, and pale skin. Option A) Increased hemoglobin in the blood is incorrect because anemia is characterized by a decrease, not an increase, in hemoglobin levels. Option B) Urobilinogen in the blood and urine is unrelated to the major physiologic effect of anemia and is not a characteristic finding in anemia. Option C) Silent bleeding into the intestinal tract is a possible cause of anemia, specifically iron-deficiency anemia, but it does not directly address the major physiologic effect underlying the resulting symptoms. Educational Context: Understanding the major physiologic effect of anemia is essential for healthcare professionals, especially in fields like hematology and nursing. Recognizing the link between reduced oxygen-carrying capacity and the symptoms of anemia helps in diagnosing and managing patients with various types of anemia. By grasping this concept, healthcare providers can provide appropriate interventions to address tissue hypoxia and improve the quality of life for individuals affected by anemia.

Correct Answer: D

Rationale: The correct answer is D) vitamin B12 and disturbed nervous system functioning. Understanding the relationship between vitamin B12 and disturbed nervous system functioning is crucial for Mrs. Young as vitamin B12 plays a key role in maintaining the health of nerve cells and producing myelin, a substance that protects nerve fibers. Deficiency in vitamin B12 can lead to neurological symptoms such as numbness, tingling, and memory problems. Option A) chemotherapy and alopecia is incorrect as chemotherapy is commonly associated with alopecia (hair loss), not vitamin B12. Option B) drinking a quart of milk daily and preventing iron deficiency is incorrect as milk is not a primary source of iron, and iron deficiency is not directly related to milk consumption. Option C) nitroglycerin and the relief of angina is incorrect as nitroglycerin is a medication used to relieve chest pain (angina) by dilating blood vessels, not related to vitamin B12. Educationally, understanding the relationship between specific nutrients like vitamin B12 and their impact on bodily functions is essential for patients to make informed decisions about their health, especially when managing conditions that are influenced by nutritional factors. This knowledge empowers individuals to take proactive steps in maintaining their well-being and seeking appropriate interventions when necessary.

Correct Answer: A

Rationale: In hematology, monitoring patients receiving blood transfusions is crucial to prevent potential complications. The correct answer is A) acute blood loss. Patients with acute blood loss are at risk of hypovolemic shock, which can lead to serious consequences such as organ failure and death. By observing the rate of flow and the patient's response to the transfusion, the nurse can assess if the therapy is effectively addressing the patient's condition. Option B) heart conditions is incorrect because although patients with heart conditions may require blood transfusions, the immediate concern for close monitoring lies with patients experiencing acute blood loss. Option C) iron deficiency anemia is incorrect as these patients usually receive iron supplementation or iron-rich foods, not necessarily blood transfusions. Option D) folic acid deficiency is incorrect because folic acid deficiency is typically treated with oral folic acid supplementation, not blood transfusions. Educationally, understanding the rationale behind the need for close monitoring of blood transfusions in specific patient populations is essential for nursing practice. Nurses must be able to differentiate which patients are at high risk for complications and require vigilant observation to ensure safe and effective care delivery. This knowledge is critical for providing quality patient care and preventing adverse outcomes.