Victorio is being managed for diarrhea. Which outcome indictes that fluid resuscitation is successful?

Correct Answer: C

Rationale: The correct answer is C because firm skin turgor indicates adequate hydration, a key goal of fluid resuscitation in diarrhea management. Firm skin turgor reflects the body's fluid balance and hydration status. When fluid resuscitation is successful, the patient's skin turgor improves due to replenished fluid levels. Choices A, B, and D are incorrect as they do not directly assess hydration status or the effectiveness of fluid resuscitation. Passing formed stools, decrease in stool frequency, and absence of perianal burning may be positive outcomes in diarrhea management, but they do not specifically indicate successful fluid resuscitation.

Correct Answer: C

Rationale: The correct answer is C because subjective data refers to information provided by the patient, such as their feelings, perceptions, and symptoms. In this case, the patient describing excitement about discharge is subjective as it is based on their personal experience. The other options (A, B, D) are objective data as they can be measured or observed directly without interpretation. The patient's temperature (A) and wound appearance (B) are physical observations, while the patient pacing the floor (D) is a behavior that can be observed. Therefore, only choice C fits the definition of subjective data in a nursing assessment.

Correct Answer: D

Rationale: The correct answer is D because all the treatment modalities listed - surgery, radiotherapy, and chemotherapy - play essential roles in managing breast cancer. Surgery removes the primary tumor, radiotherapy targets any remaining microscopic disease, and chemotherapy systematically destroys cancer cells throughout the body. Each modality addresses a different aspect of the disease, making a comprehensive treatment approach necessary for the best outcomes. Choices A, B, and C alone do not cover all necessary aspects of breast cancer treatment, hence D is the correct choice.

Correct Answer: A

Rationale: The correct answer is A (5 to 10 mcg/ml) because this range is typically considered therapeutic for phenytoin (Dilantin) for seizure control. Levels below 5 mcg/ml may be subtherapeutic, leading to inadequate seizure control. Levels above 10 mcg/ml can increase the risk of toxicity. Choices B, C, and D are incorrect because they are outside the optimal therapeutic range, leading to either ineffective treatment (B, C) or an increased risk of adverse effects (D). Monitoring drug levels helps ensure the medication's effectiveness while minimizing side effects.

Correct Answer: A

Rationale: The correct answer is A: Filtration. Albumin is a large protein molecule that cannot pass through the semipermeable membrane of blood vessels. Therefore, the shift of body fluids associated with intravenous albumin administration occurs through the process of filtration, where fluid moves across the membrane due to a pressure difference. Osmosis (B) involves the movement of water across a semipermeable membrane, which is not the case for albumin. Diffusion (C) is the movement of molecules from an area of high concentration to low concentration, which is not how albumin moves. Active transport (D) requires energy to move substances against a concentration gradient, which is not the mechanism for albumin movement in the body.

Correct Answer: C

Rationale: The correct answer is C because firm skin turgor indicates adequate hydration, a key goal of fluid resuscitation in diarrhea management. Firm skin turgor reflects the body's fluid balance and hydration status. When fluid resuscitation is successful, the patient's skin turgor improves due to replenished fluid levels. Choices A, B, and D are incorrect as they do not directly assess hydration status or the effectiveness of fluid resuscitation. Passing formed stools, decrease in stool frequency, and absence of perianal burning may be positive outcomes in diarrhea management, but they do not specifically indicate successful fluid resuscitation.

Correct Answer: B

Rationale: The correct answer is B: Severe tenderness and swelling in the scrotum. Epididymitis is characterized by inflammation of the epididymis, causing symptoms such as severe tenderness and swelling in the scrotum. Choice A is incorrect as burning and pain on urination are more indicative of a urinary tract infection. Choice C, foul-smelling ejaculate and severe scrotal swelling, is not commonly associated with epididymitis. Choice D, foul-smelling urine and pain on urination, may indicate a urinary tract infection but are not specific to epididymitis.

Correct Answer: B

Rationale: The correct answer is B: Nausea and vomiting. Chemotherapeutic drugs commonly cause nausea and vomiting due to their effect on the gastrointestinal system. This is because these drugs can irritate the stomach lining and trigger the vomiting center in the brain. Nausea and vomiting are well-documented side effects of chemotherapy and are often managed with antiemetic medications. A: Painful mouth sores are a common side effect of some chemotherapeutic drugs, but they are not the most common adverse effect. C: Frequent diarrhea can occur as a side effect of chemotherapy, but it is less common than nausea and vomiting. D: Constipation is not a common adverse effect of chemotherapeutic drugs; in fact, diarrhea is more commonly seen.

Correct Answer: A

Rationale: The correct answer is A because ranking all the patient's nursing diagnoses in order of priority allows the nurse to address the most critical needs first. By prioritizing based on the urgency and potential impact on the patient's health, the nurse can ensure that interventions are carried out effectively. B is incorrect because priorities may need to be adjusted based on the patient's changing condition. C is incorrect as priorities should consider not only physiological but also psychological and sociological factors. D is incorrect because time is an influencing factor, but it should not be the sole consideration when prioritizing interventions.