For a client with low blood volume, what are the implications of decreasing blood pressure and a rapid heart rate?

Correct Answer: D

Rationale: The correct answer is D: Hypovolemia and shock. Rationale: 1. Low blood volume leads to decreased blood pressure and rapid heart rate as compensatory mechanisms. 2. These signs indicate inadequate perfusion due to reduced blood volume. 3. Hypovolemia can progress to shock if not addressed promptly. Summary: A: Compression of blood vessels is not directly related to low blood volume. B: Increasing circulating blood volume would not occur in a client with low blood volume. C: Inadequate renal perfusion is a consequence of hypovolemia, not an implication of decreasing blood pressure and rapid heart rate.

Correct Answer: A

Rationale: The correct answer is A: Oxygen saturation above 90%. This is a discharge criterion because adequate oxygen saturation indicates the patient is breathing well and there is no immediate respiratory compromise. Oxygen saturation below 90% (choice C) would indicate hypoxemia and would not be safe for discharge. IV narcotics given less than 15 minutes ago (choice B) can still be in effect and may impair the patient's ability to function post-surgery. IV narcotics given less than 30 minutes ago (choice D) is a longer timeframe but still not ideal for discharge as the effects of the narcotics may not have fully worn off.

Correct Answer: B

Rationale: The correct answer is B because it provides a specific action (offering water) at regular intervals (every 2 hours) to promote hydration, which is a clear and measurable nursing intervention. Choice A is too prescriptive and lacks flexibility. Choice C is reactive and not proactive. Choice D is vague and lacks specific guidance on how to achieve the desired outcome. By offering water consistently, the nurse ensures proactive care and helps meet the client's hydration needs effectively.

Correct Answer: D

Rationale: The correct answer is D: Preventing bone injury. In multiple myeloma, abnormal plasma cells can weaken bones, leading to fractures. Preventing bone injury involves educating the client on fall prevention, avoiding heavy lifting, and ensuring a safe environment. Monitoring respiratory status (A) is not the priority in multiple myeloma. Restricting fluid intake (B) is not directly related to managing multiple myeloma. Balancing rest and activity (C) is important for overall well-being but does not directly address the specific needs of a client with multiple myeloma.

Correct Answer: D

Rationale: The correct answer is D: Hypovolemia and shock. Rationale: 1. Low blood volume leads to decreased blood pressure and rapid heart rate as compensatory mechanisms. 2. These signs indicate inadequate perfusion due to reduced blood volume. 3. Hypovolemia can progress to shock if not addressed promptly. Summary: A: Compression of blood vessels is not directly related to low blood volume. B: Increasing circulating blood volume would not occur in a client with low blood volume. C: Inadequate renal perfusion is a consequence of hypovolemia, not an implication of decreasing blood pressure and rapid heart rate.

Correct Answer: D

Rationale: The correct answer is D because airborne pollens and molds are common triggers for allergic rhinitis. Understanding these triggers helps in avoiding exposure and managing symptoms. Choices A, B, and C are incorrect as they do not specifically relate to allergic rhinitis triggers, focusing instead on other forms of medication or topical applications. By understanding airborne triggers, the patient can take appropriate preventive measures.

Correct Answer: D

Rationale: The correct answer is D, the bicarbonate-carbonic system. This buffer system is crucial in maintaining the body's pH balance. When CO2 combines with water in the blood, it forms carbonic acid, which dissociates into bicarbonate ions and hydrogen ions. Bicarbonate acts as a base, accepting excess hydrogen ions to prevent a decrease in pH. Hemoglobin and plasma proteins primarily function as transport molecules, not as buffer systems. Phosphate buffer system is present in intracellular fluids, not as commonly in the body. The bicarbonate-carbonic system is the most prevalent buffer system in the blood and plays a vital role in regulating blood pH.

Correct Answer: B

Rationale: The correct answer is B because asking about the frequency of bowel movements is crucial in assessing diarrhea, a common symptom. This information helps determine the severity and duration of the condition, guiding the nurse in identifying potential causes and appropriate interventions. Choice A focuses on the cause of upset stomach, not specifically diarrhea. Choice C is more related to incontinence rather than diarrhea. Choice D is important but not directly related to establishing a nursing diagnosis for diarrhea. Therefore, Choice B is the most appropriate question to assist in accurately assessing and diagnosing diarrhea.

Correct Answer: B

Rationale: The correct answer is B: Ineffective airway clearance related to obstruction by a tumor or secretions. This is the highest priority because compromised airway clearance can lead to life-threatening complications such as respiratory distress or hypoxia. Ensuring effective airway clearance is crucial in preventing respiratory compromise and maintaining oxygenation. Choices A, C, and D are not the highest priority because they do not directly address the immediate risk to the client's physiological well-being. Treating disturbed body image, anxiety, or imbalanced nutrition are important but can be addressed after ensuring the client's airway is clear and they are able to breathe effectively.