In the ICU setting, a client transported from surgery following open heart bypass grafting will likely have his or her core temperature measured by:

Correct Answer: C

Rationale: In the ICU setting, a client transported from surgery following open heart bypass grafting will likely have their core temperature measured by an esophageal thermometer. This method is preferred because it provides a more accurate reflection of the body's core temperature compared to other methods. Esophageal thermometers are inserted into the esophagus, which is close to the heart and major blood vessels, making it an ideal site for accurate temperature monitoring in critically ill patients. This is especially important in post-surgical patients where precise temperature monitoring is crucial for early detection of complications such as infection or hypothermia. The other options are not as suitable for measuring core temperature in this setting. Oral thermometers may not accurately reflect core temperature, especially in critically ill patients who may be mouth-breathing or have altered consciousness. Rectal thermometers provide a more peripheral temperature reading and are not as reliable for core temperature monitoring. Temporal artery thermometers are also peripheral and may not accurately reflect core temperature changes. Educationally, understanding the rationale behind selecting the appropriate temperature monitoring method in different clinical scenarios is crucial for providing optimal patient care. It emphasizes the importance of accurate assessment techniques to guide clinical interventions and ensure patient safety and well-being.

Correct Answer: A

Rationale: In response to an increased workload, cardiac myocardial cells will increase in size (option A). This process is known as cardiac hypertrophy, which is an adaptive mechanism to enhance the heart's contractile strength in order to meet the increased demand. As the workload on the heart increases, such as in conditions like hypertension or valvular heart disease, the myocardial cells undergo hypertrophy to generate more forceful contractions. The other options are incorrect: - Decreasing in length (option B) is not a typical response to increased workload in cardiac cells. - Increasing in excitability (option C) is not a direct response to increased workload but rather relates to the electrical properties of the cells. - Increasing in number (option D) is not a common response in cardiac cells; instead, hypertrophy is the more common response to increased workload. Understanding how cardiac cells adapt to increased workload is crucial for nurses caring for cardiac patients. Recognizing cardiac hypertrophy as a response to increased workload helps nurses anticipate complications related to cardiac function and implement appropriate interventions to support the heart's adaptation while preventing further damage.

Correct Answer: A

Rationale: In the context of chemotherapy, colony-stimulating factors play a crucial role in stimulating the production of white blood cells (leukocytes) in the bone marrow. White blood cells are essential components of the immune system and are particularly important in fighting infections. Chemotherapy often suppresses bone marrow function, leading to decreased levels of white blood cells, which can increase the risk of infections. Colony-stimulating factors help to counteract this effect by promoting the production of white blood cells, thereby supporting the immune system. In this scenario, option A (White blood cells) is the correct answer because colony-stimulating factors are specifically designed to stimulate the production of these cells. Red blood cells (option B) are not directly affected by colony-stimulating factors in response to chemotherapy. Phagocytes (option C) are a type of white blood cell involved in engulfing and destroying pathogens but are not the primary target of colony-stimulating factors. Myocardial cells (option D) are cardiac muscle cells and are not directly involved in the immune response to chemotherapy. It is crucial for healthcare professionals to understand the impact of chemotherapy on different blood cells and the role of colony-stimulating factors in maintaining the immune system during cancer treatment. By recognizing the specific effects of chemotherapy on blood cell production, healthcare providers can better manage potential complications such as infections in patients undergoing cancer treatment.

Correct Answer: B

Rationale: In a patient with renal failure, the correct nursing diagnosis that would provide the most plausible indication for the use of epoetin alfa (Epogen) is "B) Activity intolerance related to decreased oxygen-carrying capacity." Epoetin alfa is a synthetic form of erythropoietin, a hormone produced by the kidneys that stimulates red blood cell production in bone marrow. In renal failure, the kidneys are unable to produce enough erythropoietin, leading to decreased red blood cell production and subsequently decreased oxygen-carrying capacity in the blood. By administering epoetin alfa, we can stimulate red blood cell production and improve oxygen delivery to tissues, thus alleviating activity intolerance caused by tissue hypoxia. Regarding the other options: A) Risk for infection related to decreased erythropoiesis - While decreased red blood cell count can contribute to impaired immune function, epoetin alfa is not used to directly address infection risk. C) Powerlessness-related sequelae of renal failure - This is more related to psychological and emotional aspects of care and not directly linked to the physiological effects of epoetin alfa. D) Ineffective breathing pattern related to inadequate erythropoietin synthesis - While inadequate erythropoietin synthesis can lead to anemia and tissue hypoxia, the use of epoetin alfa would address the oxygen-carrying capacity concern rather than directly impacting breathing patterns. Understanding the rationale behind selecting the correct nursing diagnosis in this context is crucial for nurses to provide optimal care for patients with renal failure and associated anemia. By linking the pathophysiology of renal failure to the therapeutic action of epoetin alfa, nurses can make informed clinical decisions and improve patient outcomes.

Correct Answer: B

Rationale: In this scenario, the correct response by the nurse is option B) "The potential risks of vaccinations have been investigated and determined to be." This response is the most appropriate as it acknowledges the family's concerns while also providing them with accurate information based on scientific evidence. The rationale behind choosing option B is rooted in the principles of pharmacology and evidence-based practice. Vaccines undergo rigorous testing and continuous monitoring to ensure their safety and effectiveness. By stating that the risks of vaccinations have been thoroughly investigated and found to be minimal compared to the benefits of immunization, the nurse is providing the family with reassurance based on scientific data. Option A is incorrect because it fails to acknowledge the overwhelming evidence supporting the safety and benefits of vaccinations. Option C is inappropriate as it does not address the family's concerns and may come across as dismissive. Option D is also incorrect as it inaccurately portrays vaccines as causing serious adverse effects without emphasizing their overall safety profile. From an educational standpoint, it is crucial for healthcare professionals to address vaccine hesitancy with empathy, understanding, and evidence-based information. By engaging in open and respectful dialogue with families, nurses can help dispel myths and misconceptions surrounding vaccines, ultimately promoting public health and protecting vulnerable populations from preventable diseases.