When monitoring for hypernatremia, the nurse should assess the client for:

Correct Answer: C

Rationale: Hypernatremia is a condition characterized by high levels of sodium in the blood. When monitoring for hypernatremia, the nurse should assess the client for signs of neurologic impairment, such as confusion. This is because hypernatremia can lead to changes in mental status due to the hyperosmolarity of the blood affecting brain function. Assessing for confusion is crucial in identifying and managing hypernatremia promptly to prevent further complications. Dry skin, tachycardia, and pale coloring are not specific manifestations of hypernatremia and are less likely to be directly related to this electrolyte imbalance.

Correct Answer: A

Rationale: Monitoring the client's temperature before, during, and after transfusion is essential to determine if chilling is the result of an emerging complication or of infusing cold blood. By consistently monitoring the client's temperature at different points in the transfusion process, healthcare providers can identify any significant changes that may indicate a complication. This allows for timely intervention and appropriate management of any issues related to the blood transfusion. Comparing the client's temperature with the temperature of the blood is important but alone it may not provide a comprehensive assessment of the client's condition during the transfusion process. So, the best course of action is to monitor the client's temperature at various time points to ensure accurate assessment and early detection of any complications.

Correct Answer: A

Rationale: Narcotic analgesics, when given in high doses, can depress the respiratory rate and cough reflex in patients. Laryngectomy patients have had their larynx removed and may already have compromised respiratory function. Therefore, giving narcotics in low doses helps to minimize the risk of further respiratory depression in these patients. It is important to closely monitor respiratory status when administering narcotics to laryngectomy patients to prevent potential complications.

Correct Answer: A

Rationale: The nurse should examine the entire system and tubing for air leaks when observing vigorous bubbling in the water-seal chamber of a chest-drainage system. Vigorous bubbling indicates that there is air escaping from the system, which can lead to suboptimal drainage and potential complications. By identifying and correcting any air leaks, the nurse can ensure the chest-drainage system functions effectively, allowing for proper drainage and the prevention of complications such as pneumothorax. Lowering the level of suction or asking the patient to cough forcefully would not address the underlying issue of air leaks and may not resolve the problem effectively.

Correct Answer: A

Rationale: Prophylactic antibiotics are given to prevent the recurrence or complications of endocarditis in patients with a history of the condition. Endocarditis is an infection of the inner lining of the heart chambers and valves. One of the serious complications of endocarditis is the formation of vegetative emboli, which are clusters of bacteria and fibrin that can break off and travel through the bloodstream, potentially causing blockages in various organs. By preventing endocarditis, the antibiotics also help reduce the risk of vegetative emboli formation during surgical procedures or other situations where bacteria may enter the bloodstream. Therefore, the nurse's explanation to the patient about the prophylactic antibiotics is focused on preventing complications related to endocarditis, including the formation of vegetative emboli.