A client is postoperative with shallow respirations at 9/min. Which acid-base imbalance should the nurse identify the client as being at risk for developing initially?

Correct Answer: A

Rationale: The correct answer is A: Respiratory acidosis. Shallow respirations at 9/min indicate hypoventilation, leading to retention of CO2 and respiratory acidosis. This is because inadequate removal of CO2 results in an increase in carbonic acid concentration, leading to a decrease in blood pH. Respiratory alkalosis (B) is unlikely with shallow respirations. Metabolic acidosis (C) results from nonrespiratory factors. Metabolic alkalosis (D) is not related to respiratory rate.

Correct Answer: B

Rationale: The correct answer is B: Increasing dyspnea. Atelectasis is a condition where the lung tissue collapses, leading to decreased oxygen exchange and resulting in symptoms like dyspnea (difficulty breathing). This occurs because the collapsed lung tissue reduces the surface area available for gas exchange, leading to decreased oxygen saturation and increased work of breathing. Facial flushing (choice A) is not typically associated with atelectasis. Decreasing respiratory rate (choice C) may not be a reliable indicator as the body may compensate by increasing respiratory rate to maintain oxygenation. Friction rub (choice D) is more commonly associated with conditions like pleurisy or pneumonia, not atelectasis.

Correct Answer: C

Rationale: The correct answer is C: Heparin. Heparin is a common anticoagulant used to prevent further clotting in patients with pulmonary embolism. It works by inhibiting blood clot formation. Furosemide (A) is a diuretic used for conditions like heart failure and edema, not for pulmonary embolism. Dexamethasone (B) is a corticosteroid used for inflammation and immune suppression, not for pulmonary embolism. Atropine (D) is used to treat bradycardia and not indicated for pulmonary embolism. Administering heparin is crucial to prevent worsening of the pulmonary embolism and potential life-threatening complications.

Correct Answer: A

Rationale: In the context of pharmacology and medical-surgical nursing, understanding the relationship between decreased plasma volume and cardiac output is crucial. The correct answer is A) Flattened neck veins when the client is in a supine position. This finding supports the nursing diagnosis of Decreased Cardiac Output because decreased plasma volume leads to reduced preload, resulting in decreased venous return to the heart. In the supine position, flattened neck veins indicate decreased venous return and impaired filling of the right side of the heart, ultimately leading to decreased cardiac output. Option B) Full and bounding pedal and post-tibial pulses is incorrect because this finding is more indicative of increased cardiac output or volume overload rather than decreased cardiac output related to decreased plasma volume. Option C) Pitting edema located in feet, ankles, and calves is incorrect as it is a sign of fluid retention, typically seen in conditions like heart failure where there is an excess of fluid volume, not decreased plasma volume. Option D) Shallow respirations with crackles on auscultation is more indicative of respiratory issues such as pulmonary edema rather than decreased cardiac output related to decreased plasma volume. Understanding these clinical findings in the context of pharmacology helps nurses make accurate assessments and diagnose alterations in cardiac function promptly, leading to appropriate interventions to improve patient outcomes.

Correct Answer: A

Rationale: In this scenario, the correct action that can be delegated to the nursing assistant is to provide oral care every 3-4 hours (Option A). This task is within the scope of practice for a nursing assistant and helps maintain the client's oral hygiene, which is important in preventing infections and promoting comfort. Monitoring for indications of dehydration (Option B) and administering 0.45% saline by IV line (Option C) are tasks that require a higher level of clinical judgment and understanding of the client's condition, which should be performed by a registered nurse. Assessing daily weights for trends (Option D) is also a critical nursing responsibility that involves interpreting and analyzing data to monitor the client's fluid status accurately. Educationally, understanding the principles of delegation is crucial for newly graduated RNs. Delegating tasks effectively involves considering the complexity of the task, the stability of the client, and the competency of the healthcare team members. By delegating appropriate tasks, RNs can optimize client care outcomes and promote teamwork within the healthcare setting.