Which of the ff nursing interventions is required when caring for a client after cardiac surgery who is at risk for ineffective tissue perfusion?

Correct Answer: C

Rationale: When caring for a client after cardiac surgery who is at risk for ineffective tissue perfusion, it is important to promote optimal blood flow to the tissues. Positioning the lower extremities below the level of the heart helps to facilitate venous return and improve circulation to the extremities. This position helps reduce the workload on the heart and promotes better perfusion to the tissues, ultimately aiding in the prevention of complications related to ineffective tissue perfusion. The other options (A. Restrict fluid intake, B. Ensure that the client avoids prolonged sitting, D. Instruct the client to avoid leg exercises) are not directly related to improving tissue perfusion and may not be appropriate interventions in this situation.

Correct Answer: B

Rationale: IV morphine is the most appropriate choice among the options provided for quickly reducing shortness of breath (SOB) in a crisis situation for a patient with end-stage respiratory disease. Morphine is commonly used in palliative care for symptom management in patients with severe respiratory distress. It acts as a respiratory depressant by reducing the perception of breathlessness, which can help alleviate the distressing symptoms of dyspnea. The rapid onset of action of IV morphine makes it an effective option for immediate relief in emergency situations for patients experiencing significant SOB due to end-stage respiratory disease. Oral cortisone, IM meperidine (Demerol), and IV propranolol (Inderal) are not primary choices for quickly reducing SOB in this context.

Correct Answer: A

Rationale: During a uterosigmoidostomy procedure for treating a malignant tumor, a critical task of the nurse is to inspect for bleeding or cyanosis. Bleeding can be a potential complication during surgery and needs to be promptly identified and managed by the nurse. Cyanosis, which is a bluish discoloration of the skin due to lack of oxygen, can indicate a lack of blood flow to the tissues. Both bleeding and cyanosis are serious issues that require immediate attention to prevent further complications and ensure the client's safety and well-being. Therefore, assessing and monitoring for these signs are crucial tasks for the nurse in this situation.

Correct Answer: C

Rationale: Unintentional injuries are the major cause of death for children older than 1 year. These include accidents such as drownings, car accidents, fires, falls, and poisoning. Children are curious and naturally explore their environment, which can put them at risk for accidents. It is important for parents and caregivers to create safe environments for children, supervise them closely, and take appropriate safety precautions to prevent these injuries. By being mindful of potential hazards and actively working to prevent accidents, we can help reduce the incidence of unintentional injuries and protect children's well-being.

Correct Answer: D

Rationale: A patient experiencing an exacerbation of COPD, especially due to an infection, requires a diet that is high in calories and protein. This is because during exacerbations, the body's energy requirements increase due to increased work of breathing and inflammation. High-calorie intake helps provide the necessary energy for breathing and healing. Additionally, a high-protein diet is important for maintaining respiratory and skeletal muscle strength, which can be affected during exacerbations of COPD. Therefore, a high-calorie high-protein diet would be most appropriate for Aling Maria to support her recovery and overall health during this period.