Which of the ff values pertaining to different clients shows the normal range of plasma pH?

Correct Answer: A

Rationale: The correct answer is A: 7.35-7.45. Plasma pH typically falls within this range for normal clients. A pH of 7.35-7.45 indicates a slightly alkaline to neutral environment, which is essential for various physiological processes to function optimally. Choices B, C, and D have pH values outside the normal range, indicating either acidic (B and C) or highly alkaline (D) conditions, which would be abnormal and potentially harmful to the body's functioning. Therefore, the normal range for plasma pH is crucial to maintain homeostasis and support overall health.

Correct Answer: C

Rationale: The correct answer is C: Hematuria. Bacillus Calmette-Guerin (BCG) is a type of immunotherapy used to treat bladder cancer by stimulating the immune system to attack cancer cells. One common side effect of BCG instillations is hematuria, which is the presence of blood in the urine. This occurs because BCG irritates the bladder lining, leading to inflammation and bleeding. It is important for the nurse to educate the client about this potential side effect so they are aware and can report any excessive bleeding to their healthcare provider promptly. Other choices are incorrect: A: Renal calculi - BCG therapy is not known to cause renal calculi. B: Delayed ejaculation - BCG therapy is not associated with delayed ejaculation. D: Impotence - BCG therapy is not linked to impotence.

Correct Answer: D

Rationale: The correct answer is D: Hyperparathyroidism. This disorder is characterized by excessive secretion of parathyroid hormone, leading to increased calcium levels in the blood. The symptoms described in the question - bone pain, weakness, irritability, and depression - are all associated with hypercalcemia, a common manifestation of hyperparathyroidism. Additionally, the client's anorexia and increased urination can be attributed to the effects of hypercalcemia on the gastrointestinal and renal systems. Diabetes mellitus (choice A) involves high blood sugar levels and is not associated with the symptoms described. Hypoparathyroidism (choice B) is characterized by low levels of parathyroid hormone and calcium, leading to different symptoms such as muscle cramps and seizures. Diabetes insipidus (choice C) is a disorder of water balance characterized by excessive thirst and urination, not the symptoms presented in the question.

Correct Answer: B

Rationale: The correct answer is B: ELISA and Western Blot. The rationale is as follows: ELISA (enzyme-linked immunosorbent assay) and Western Blot are specific tests used to confirm HIV infection by detecting antibodies or antigens related to the virus. ELISA is the initial screening test, while Western Blot is the confirmatory test. These tests are highly sensitive and specific for HIV detection. Choice A is incorrect because CD4+ cell count and thymus function are not tests used to confirm HIV infection. They are used to monitor disease progression and immune function in HIV-positive individuals. Choice C is incorrect because B-cell and T-cell count are also not tests used to confirm HIV infection. They are indicators of immune system health but not specific for HIV diagnosis. Choice D is incorrect because while CD4+ and viral load tests are used in monitoring HIV progression, ELISA is the main confirmatory test for HIV diagnosis, and viral load is not typically used for initial

Correct Answer: B

Rationale: The correct answer is B: Keep extremities at neutral position. This intervention promotes proper blood flow and reduces the risk of thrombophlebitis by preventing compression or restriction of blood vessels. Removing and reapplying elastic stockings (choice A) can disrupt circulation and increase the risk of thrombophlebitis. Changing the client's position (choice C) may not directly address hemostasis or thrombophlebitis. Using a flotation mattress (choice D) is not specifically focused on maintaining proper positioning of the extremities to promote circulation.

Correct Answer: A

Rationale: Step 1: Regular aerobic exercise helps lower blood pressure by improving heart health and circulation. Step 2: Exercise reduces stress and promotes weight loss, factors that contribute to hypertension control. Step 3: Alcohol consumption can raise blood pressure and should be limited or avoided. Step 4: Smoking and using low-tar cigarettes can still raise blood pressure and have other negative health effects. Step 5: Daily multivitamin supplements do not directly impact blood pressure control.

Correct Answer: C

Rationale: The correct answer is C because subjective data refers to information provided by the patient based on their feelings, perceptions, and experiences. In this case, the patient describing excitement about discharge is subjective data as it reflects the patient's emotional state. The other choices, A, B, and D, are considered objective data because they are observable and measurable by the nurse. The patient's temperature can be measured (A), the wound appearance can be visually assessed (B), and the patient pacing the floor is an observable behavior (D). Therefore, these choices are not subjective data.

Correct Answer: A

Rationale: The correct answer is A: Vision changes. Tamoxifen can cause serious ocular side effects like retinopathy and corneal changes. These adverse reactions can lead to vision impairment or loss, which is crucial to report immediately to prevent permanent damage. Headache (B), hearing loss (C), and anorexia (D) are not typically associated with tamoxifen use and do not pose immediate threats to the client's health compared to vision changes. It is important for the nurse to prioritize educating the client on recognizing and reporting vision changes promptly to ensure timely intervention and prevent irreversible consequences.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Asking if the patient feels the need to go to the bathroom helps assess urgency. 2. Urinary retention may lead to the inability to sense the urge to void. 3. This question directly addresses the issue of voiding, crucial in diagnosing urinary retention. Summary: B: Mobility is not directly related to urinary retention. C: Medication timing is important but not directly related to urinary retention. D: Safety rail inquiry is more related to fall prevention, not urinary retention.