When a patient is receiving diuretic therapy, which of these assessment measures would best reflect the patient's fluid volume status?

Correct Answer: C

Rationale: The correct answer is C because assessing the patient's intake, output, and daily weight provides direct information on fluid balance. Intake measures fluid coming in, output measures fluid going out, and daily weight reflects changes in total body water. Blood pressure and pulse (A) are affected by various factors and may not solely indicate fluid status. Serum potassium and sodium levels (B) are affected by multiple factors, not just fluid volume. Measurements of abdominal girth and calf circumference (D) are more specific to assessing for fluid retention in certain areas, not overall fluid volume status.

Correct Answer: B

Rationale: The correct answer is B: Cool, clammy skin. Following a myocardial infarction, the client may experience hypotension due to decreased cardiac output. Cool, clammy skin indicates poor peripheral perfusion, a common manifestation of hypotension. This finding suggests inadequate blood flow to the skin. The other choices are incorrect because: A: A heart rate of 120 beats/min may indicate tachycardia, which is a compensatory mechanism to maintain cardiac output in response to hypotension. C: An oxygen saturation of 90% is below the normal range but is not a typical assessment finding related to hypotension after a myocardial infarction. D: A respiratory rate of 8 breaths/min is abnormally low but not directly related to hypotension post-myocardial infarction.

Correct Answer: B

Rationale: The correct answer is B, a 52-year-old in a tripod position using accessory muscles to breathe. This client is likely experiencing respiratory distress, which is a medical emergency in COPD. The tripod position and use of accessory muscles indicate increased work of breathing and potential respiratory failure, requiring immediate assessment and intervention to prevent further deterioration. Incorrect choices: A: Smoking history is relevant but does not indicate immediate respiratory distress. C: Dependent edema and clubbed fingers suggest advanced disease but not acute respiratory distress. D: Chronic cough and thick secretions are common in COPD but do not indicate acute respiratory compromise.

Correct Answer: C

Rationale: The correct answer is C: Is the delegated task permitted by law? This is the first question the nurse must ask before delegating medication administration to an unskilled assistant. The rationale is that delegation must comply with legal regulations to ensure patient safety and avoid legal implications. If the task is not permitted by law, the nurse should not delegate it. Choice A (Has the assistant been trained to perform the task?) is important but comes after ensuring the task is legally permitted. Choice B (Have I evaluated the patients response to this task?) is about patient assessment, not legality. Choice D (Is appropriate supervision available?) is relevant but should come after confirming the task's legality.

Correct Answer: C

Rationale: The primary focus of healthcare today is health promotion (Choice C) because it emphasizes preventive measures to maintain overall well-being and reduce the burden of diseases. Health promotion involves educating individuals on healthy lifestyle choices, disease prevention, and early detection. This approach aligns with the shift towards proactive rather than reactive healthcare. Incorrect options: A: Care of acute illnesses - This option focuses on treating immediate health issues rather than preventing them. B: Care of chronic illnesses - While important, this option addresses managing ongoing conditions rather than prioritizing prevention. D: Health restoration - This choice emphasizes restoring health after illness, which is essential but not the primary focus of healthcare today.