If a Wall unit is used, What should be the suctioning pressure required by James?

Correct Answer: C

Rationale: Step 1: The optimal suctioning pressure for adults is usually between 80-120 mmHg. Step 2: Choice C falls within this recommended range (95-110 mmHg). Step 3: Higher pressures (like in choices B and D) can cause tissue damage. Step 4: Lower pressures (like in choice A) may not effectively remove secretions. Summary: Choice C (95-110 mmHg) is correct as it falls within the safe and effective suctioning pressure range for adults, while the other choices are either too high or too low, risking harm or inefficiency.

Correct Answer: D

Rationale: The correct action for the nurse to take first is to obtain a Doppler and recheck the pedal pulses. This is the correct choice because it allows the nurse to further assess the circulation in the lower extremities. By using a Doppler, the nurse can accurately detect the presence or absence of pedal pulses, which is crucial in evaluating the severity of the patient's condition. This step provides objective data that can guide the next course of action. Choice A is incorrect because emergency surgery should not be anticipated without further assessment. Choice B is incorrect as assessing apical and radial pulses is not relevant in this situation. Choice C is incorrect as elevating the foot of the bed and applying warm compress may not address the underlying circulation issue.

Correct Answer: C

Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to gather objective data directly from the patient's body, such as vital signs, appearance, and physical findings. It is essential for establishing a patient's baseline health status and identifying any abnormalities or changes. Reviewing literature (A) is important but not a method of data collection. Checking orders (B) is part of the assessment process but does not involve direct data collection. Ordering medications (D) is a clinical intervention and not a data collection method.

Correct Answer: C

Rationale: The correct answer is C: 2, 3, and 4. High cholesterol, cigarette smoking, and a sedentary lifestyle are modifiable risk factors for developing hypertension. High cholesterol can lead to atherosclerosis, increasing blood pressure. Smoking can constrict blood vessels, raising blood pressure. Sedentary lifestyle can lead to obesity and overall poor cardiovascular health, contributing to hypertension. Race and age are non-modifiable risk factors. Choice A is incorrect because it includes race, a non-modifiable factor. Choice B is incorrect because it includes age, which is also non-modifiable. Choice D is incorrect because it includes all factors, including non-modifiable ones.

Correct Answer: B

Rationale: The correct answer is B: Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing. This nursing diagnosis takes highest priority for a client with hyperparathyroidism because the client is at risk for skin breakdown due to edema, skin fragility, and poor wound healing caused by the condition. Skin integrity is crucial for preventing infection and promoting overall health. Choice A is incorrect because hyperparathyroidism is not related to thyroid hormone excess, but rather to parathyroid hormone excess. Choice C is incorrect because body image disturbance is not the highest priority compared to the risk of skin breakdown. Choice D is incorrect because hyperparathyroidism typically leads to hypercalcemia and not imbalanced nutrition related to thyroid hormone excess.

Correct Answer: D

Rationale: The correct answer is D: throbbing headache. Nitroglycerin is a vasodilator that relaxes blood vessels, leading to increased blood flow and reduced workload on the heart. One common side effect of nitroglycerin is a throbbing headache due to the dilation of blood vessels in the brain. This side effect is expected and usually diminishes with continued use. Explanation of other choices: A: High blood pressure - Nitroglycerin actually helps lower blood pressure by dilating blood vessels. B: GIT irritation - This is not a common side effect of nitroglycerin, as it primarily affects the cardiovascular system. C: Shortness of breathing - This is not a typical side effect of nitroglycerin, as it does not directly affect respiratory function.

Correct Answer: A

Rationale: The correct answer is A: Hypertension. In hypovolemia, the body compensates by increasing heart rate (B: Tachycardia) to maintain perfusion, decreasing urine output (C: Oliguria) to conserve fluid, and increasing respiratory rate (D: Tachypnea) to improve oxygenation. Hypertension is not a typical compensatory response to hypovolemia; instead, blood pressure tends to decrease due to reduced circulating volume. Therefore, hypertension is the symptom that would not be expected in a patient with hypovolemic shock.

Correct Answer: C

Rationale: The correct answer is C: Urine output increases. This indicates digoxin's effectiveness as it improves cardiac output by enhancing contraction strength. Increased urine output signifies improved kidney perfusion due to enhanced cardiac function. Option A is incorrect as decreased urine output indicates poor kidney perfusion. Option B is incorrect as digoxin aims to regulate heart rate, not necessarily make it higher than 95. Option D is incorrect as a heart rate lower than 50 could indicate digoxin toxicity.

Correct Answer: B

Rationale: The correct answer is B: Drinking cranberry juice. Cranberry juice is known to help reduce urinary odor due to its acidic nature which can help eliminate bacteria that cause odor. It also helps to maintain urinary tract health. The other choices are incorrect because: A: Eating spicy foods can actually increase body odor and may not have any impact on urinary odor. C: Foods like eggs, asparagus, or cheese may contribute to strong body odor but do not specifically address urinary odor. D: Drinking tea, coffee, and colas can potentially worsen urinary odor due to their caffeine content and impact on urinary tract health.