When admitting a 5-month-old who has vomited 9 times in the past 6 hours, what should the healthcare provider observe for signs of which overall imbalance?

Correct Answer: B

Rationale: When a 5-month-old infant vomits multiple times, there is a risk of developing metabolic alkalosis due to the loss of stomach acid. Metabolic alkalosis is characterized by elevated pH and bicarbonate levels. It is caused by the loss of hydrogen ions from the body, often through vomiting. Metabolic acidosis (choice A) is unlikely in this scenario because it is more commonly associated with conditions like renal failure or diabetic ketoacidosis. Choice C, increased serum hemoglobin levels, is not typically a direct consequence of vomiting. Choice D, decreased serum potassium levels, may occur with vomiting but is not the primary concern when a patient is vomiting excessively.

Correct Answer: D

Rationale: A saturated abdominal dressing may indicate active bleeding or other complications that require immediate intervention. This finding suggests a potential surgical site issue that needs urgent attention to prevent further complications. Absent bowel sounds, pain level, and a slightly elevated temperature are common post-operative findings that may not necessarily require immediate intervention compared to a saturated abdominal dressing. Absent bowel sounds can be common after surgery due to anesthesia but may resolve with time. Pain and slightly elevated temperature are expected post-operative findings that can be managed with appropriate pain relief and monitoring. However, a saturated abdominal dressing indicates a potential ongoing issue at the surgical site that needs prompt assessment and intervention to prevent complications.

Correct Answer: D

Rationale: The correct answer is 'D: I can take aspirin if I have a headache.' This statement indicates a need for further teaching because aspirin can increase the risk of bleeding in clients taking warfarin. Clients on warfarin therapy should avoid taking aspirin or any other medications that can increase the risk of bleeding without consulting their healthcare provider. Choices A, B, and C are correct statements that demonstrate understanding of warfarin therapy and its potential side effects. Avoiding foods high in vitamin K helps maintain the effectiveness of warfarin, taking medication at the same time every day ensures consistent therapeutic levels, and using a soft toothbrush helps prevent gum bleeding, which can be a side effect of warfarin therapy.

Correct Answer: C

Rationale: Shortness of breath is the most concerning symptom in a client with deep vein thrombosis (DVT) because it could indicate a pulmonary embolism, a life-threatening complication where a blood clot travels to the lungs. This condition requires immediate medical attention. While pain, redness, warmth, and swelling in the affected leg are common symptoms of DVT, shortness of breath suggests a more critical situation that necessitates urgent intervention.

Correct Answer: B

Rationale: The most appropriate initial nursing action when a client develops a rash and itching while receiving intravenous antibiotics is to discontinue the antibiotic infusion. This is crucial to prevent further allergic reactions. Administering diphenhydramine (Benadryl) (Choice A) can be considered after discontinuing the antibiotic infusion. Applying a cool compress to the rash (Choice C) may provide symptomatic relief but does not address the underlying cause. Notifying the healthcare provider (Choice D) is important but should come after discontinuing the antibiotic infusion to ensure the client's safety.