When evaluating a client's response to fluid replacement therapy, the observation that indicates adequate tissue perfusion to vital organ is;

Correct Answer: A

Rationale: The correct answer is A: Urinary output of 30 ml in an hour. Adequate tissue perfusion is best indicated by a sufficient urinary output, as it demonstrates proper kidney perfusion and function. A low urinary output may suggest inadequate perfusion. Explanation for other choices: B: Central venous pressure reading of 2 cm H20 is not a reliable indicator of tissue perfusion to vital organs. C: Pulse rates alone are not enough to indicate tissue perfusion as they can be influenced by various factors. D: Blood pressure readings alone may not accurately reflect tissue perfusion, especially in the context of fluid replacement therapy.

Correct Answer: B

Rationale: The correct answer is B: It minimizes the risk of circulatory overload. When a venous access device dislodges during a transfusion, there is a risk of the infusion going into the surrounding tissues instead of the vein, leading to circulatory overload. This can result in fluid overload and potentially lead to serious complications such as heart failure. Monitoring the device ensures that the medication is delivered safely and effectively into the bloodstream. Choices A, C, and D are incorrect: A: Monitoring the device does not directly minimize the risk of phlebitis, which is inflammation of the vein. C: Monitoring the device does not directly minimize the risk of pulmonary complications, which are not typically associated with a dislodged venous access device. D: Monitoring the device does not directly minimize the risk of localized edema embolism, which is a blockage caused by a blood clot, air bubble, or other material in a blood vessel.

Correct Answer: C

Rationale: The correct answer is C: “Be sure to protect your tracheostomy from pollutants such as powders, hair, and chemicals.” This instruction is appropriate because keeping the tracheostomy site clean and free from pollutants is crucial in preventing infections and complications. Powders, hair, and chemicals can lead to irritation and blockages, increasing the risk of infection. Explanation of why other choices are incorrect: A: “Never suction your tracheostomy; you might damage your trachea.” - This is incorrect because suctioning is a necessary part of tracheostomy care to clear secretions and ensure proper breathing. B: “You should not feel bad about the tracheostomy – you should feel lucky to be alive.” - This is incorrect as it does not provide practical instructions for tracheostomy care and may not address the patient's emotional concerns adequately. D: “Your tracheostomy will be cleaned each time you visit your doctor.” - This is

Correct Answer: C

Rationale: The correct answer is C: Auscultate lung sounds. By auscultating lung sounds, the nurse can assess for changes in breath sounds which can indicate improvement or deterioration in the patient's condition. This helps monitor the effectiveness of therapy for a pneumothorax and chest-drainage system. Palpating for crepitus (A) is not directly related to monitoring therapy effectiveness. Documenting sputum color and amount (B) is important but does not specifically monitor therapy effectiveness. Monitoring suction level (D) is crucial but does not directly assess the patient's response to therapy.

Correct Answer: D

Rationale: The correct answer is D. Taking piroxicam with food or an oral antacid can help reduce GI irritation as it can protect the stomach lining. Piroxicam is known to cause GI upset due to its effects on prostaglandin synthesis. Spacing the administration every 4 hours (choice A) may not necessarily prevent GI upset. Using the drug for a short time only (choice B) may not address the immediate concern of GI irritation. Decreasing the piroxicam dosage (choice C) may not be necessary if taking it with food or an antacid can effectively alleviate the GI upset.