Which of the following assessment data is expected in a patient admitted with extracellular fluid excess?

Correct Answer: C

Rationale: Extracellular fluid excess (e.g., heart failure) increases blood volume, distending jugular veins as pressure rises in the venous system. Elevated hematocrit indicates dehydration, not excess. A rapid, thready pulse suggests hypovolemia, and increased sodium isn't typical unless concentrated. Nurses assess jugular distension to detect fluid overload, guiding diuretics or fluid restriction to prevent complications like pulmonary edema.

Correct Answer: D

Rationale: By providing medication teaching and confirming understanding through repetition, the nurse acts as an educator. This role involves imparting knowledge, ensuring comprehension, and empowering the patient to manage post-thyroidectomy care, like medication adherence, critical for recovery and preventing complications (e.g., hypothyroidism). Asking the patient to repeat instructions assesses learning, addressing gaps before discharge. As a manager, the nurse coordinates care, not directly teaches. The caregiver role focuses on physical assistance (e.g., wound care), not education. Patient advocacy ensures rights and preferences are upheld, but this scenario emphasizes teaching over advocacy. Education equips the patient for self-care, aligning with nursing's holistic approach, making educator the nurse's primary role here, enhancing health outcomes through informed participation.

Correct Answer: D

Rationale: Subjective data are the client's perceptions about their health like reporting pain or fatigue captured through interviews or questionnaires. These reflect personal experiences, not measurable by others, distinguishing them from objective data (e.g., temperature). Physician history forms provide mixed data, often objective (e.g., lab results), not purely subjective unless quoting the client. Observations by the collector like rash appearance are objective, directly seen or measured. Ancillary reports (e.g., radiology) are objective, based on tests, not perceptions. Subjective data's focus on the client's voice e.g., 'I feel anxious' is vital for holistic assessment, guiding nurses to explore symptoms' impact, making it the correct definition here.

Correct Answer: B

Rationale: Surgical asepsis, or sterile technique, is required for procedures breaching sterile areas like urinary catheterization where the bladder must remain free of microbes to prevent infection. Inserting a catheter through the urethra demands sterile gloves, drapes, and equipment, as contamination risks urinary tract infections. Vaginal instillation of estrogen uses clean technique, not sterile, as the vagina has normal flora. Nasogastric tube insertion requires clean technique; the stomach isn't sterile, tolerating minor contamination. Colostomy irrigation also uses clean technique, managing an already exposed site. Urinary catheterization's invasive nature and sterile field necessity make it the procedure always requiring surgical asepsis, aligning with infection prevention standards in nursing.

Correct Answer: C

Rationale: Side rails up at all times is the most direct safety measure for a newly hospitalized client.