When you report on duty, your team leader tells you that Mr. MartineHi accidentally received 1000 ml of fluids in 2 hours and that you are to be alert for signs of circulatory overload. Which of the following signs would not be likely to occur?

Correct Answer: C

Rationale: Circulatory overload is a condition where there is an excessive volume of fluid circulating in the bloodstream. Signs of circulatory overload include moist gurgling respirations, distended neck veins, dyspnea, and coughing. A weak, slow pulse would not be a typical sign of circulatory overload; in fact, it could indicate other conditions such as bradycardia or hypovolemia. Therefore, a weak, slow pulse would not likely occur as a sign of circulatory overload in this scenario.

Correct Answer: B

Rationale: The appropriate nursing intervention for a 19-year-old student experiencing symptoms of respiratory alkalosis related to an anxiety attack is to have him breathe into a paper bag. Breathing into a paper bag can help increase the level of carbon dioxide in the body, which can help correct respiratory alkalosis. This technique helps to rebalance the level of carbon dioxide in the blood and alleviate the symptoms of alkalosis caused by hyperventilation during the anxiety attack. It is important to monitor the student's condition and ensure that he is using the paper bag correctly to avoid any potential risks associated with this intervention. Additionally, providing reassurance and support during this episode can also be beneficial in helping the student to manage his anxiety and respiratory alkalosis.

Correct Answer: D

Rationale: Early symptoms of cancer of the larynx typically include persistent hoarseness or a change in the voice quality. This may be due to the tumor affecting the vocal cords. Dysphagia, or difficulty swallowing, can also be an early sign. As the tumor grows, it may cause obstruction or compression in the throat, leading to difficulties in swallowing. These symptoms should prompt further evaluation by a healthcare provider for proper diagnosis and treatment planning. Anemia and fatigue (Choice A) are more general symptoms that can occur in cancer patients but are not typically specific to laryngeal cancer. The presence of a noticeable lump in the neck (Choice B) may indicate swelling of lymph nodes due to cancer spread but is not an early symptom commonly associated with laryngeal cancer. Crackles and stridor (Choice C) are respiratory sounds associated with conditions affecting the airways and are less likely to be early symptoms

Correct Answer: C

Rationale: Oxygen therapy for patients with emphysema aims to maintain adequate oxygen levels in the blood while avoiding toxic levels of oxygen. The recommended flow rate for oxygen administration in patients with emphysema is typically 1-3 liters per minute. Increasing the flow rate above this range may lead to oxygen toxicity in these patients. Therefore, a safe and appropriate oxygen flow rate for a patient with emphysema would be around 6 L/min, making option C, 6 L/min, the correct choice from the provided options.

Correct Answer: B

Rationale: Acute respiratory distress syndrome (ARDS) is a serious condition that can lead to various complications, including renal failure. When a client is experiencing ARDS, the lungs become severely inflamed and filled with fluid, which can lead to decreased oxygen levels in the blood. This decrease in oxygen can place a significant strain on the kidneys, potentially resulting in renal failure. Therefore, it is crucial for nurses to monitor the client for signs and symptoms of renal failure, such as changes in urine output, fluid imbalance, electrolyte abnormalities, and altered mental status. Timely detection and management of renal complications in clients with ARDS are essential to prevent further deterioration of the client's condition.