The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes that a risk exists of cerebrovascular accidents (strokes). Which is an important objective to decrease this risk?

Correct Answer: C

Rationale: In a child with persistent hypoxia secondary to a cardiac defect, promoting cardiac output is crucial to decreasing the risk of cerebrovascular accidents (strokes). Hypoxia resulting from the cardiac defect can lead to inadequate oxygen supply to the brain, increasing the risk of strokes. By optimizing cardiac output, the body can deliver sufficient oxygen to vital organs, including the brain, reducing the likelihood of cerebrovascular accidents. It is essential to focus on supporting cardiac function to improve overall perfusion and oxygenation levels, ultimately helping to mitigate the risk of strokes in this vulnerable population.

Correct Answer: B

Rationale: Nocturia is the condition of waking up during the night to urinate. The factors associated with it are usually related to Increased nocturnal urine production (2), aging and hormonal changes (3), underlying medical conditions such as diabetes and heart disease (5), and medications that can increase urine production or cause fluid retention (6). Therefore, the correct choices are 2, 3, 5, and 6 which align with B.

Correct Answer: A

Rationale: The nurse should report the ulcer to the admitting care provider as the first action. An ulcerated area on the penis in an older adult may be indicative of various serious conditions, such as sexually transmitted infections (STIs) or skin breakdown. It is important for the healthcare provider to assess the ulcer, determine the cause, and initiate appropriate treatment. Reporting the finding promptly ensures timely intervention and appropriate management of the patient's condition. This initial action takes priority over teaching about STD prevention or inquiring about the patient's history of syphilis. Cleaning the ulcer without proper assessment and diagnosis by a healthcare provider can potentially worsen the patient's condition.

Correct Answer: C

Rationale: Insensible losses are the fluid losses that occur without the individual being aware of it, such as through breathing, sweating, and through the skin. In an afebrile person, insensible losses are normally around 600ml per 24 hours. This amount can vary depending on factors such as temperature, humidity, and individual metabolism. When a patient is febrile and experiencing diaphoresis (excessive sweating), the fluid output can increase significantly due to the body's attempts to cool itself down. It is important for the nurse to consider these increased fluid losses when planning fluid replacement for a febrile patient to prevent dehydration.

Correct Answer: B

Rationale: Metabolic acidosis is a condition characterized by a low pH (acidemia) and a low plasma bicarbonate concentration. In this condition, the body either produces too much acid, kidneys cannot remove enough acid, or there is a bicarbonate loss. This leads to an excess of hydrogen ions in the body, resulting in a decrease in pH and bicarbonate levels. Respiratory acidosis, on the other hand, is characterized by a low pH and a high carbon dioxide concentration. Respiratory alkalosis is characterized by a high pH and a low carbon dioxide concentration. Metabolic alkalosis is characterized by a high pH and a high bicarbonate concentration.