Which of the following BP changes alerts the nurse to increasing ICP, and should be reported immediately?

Correct Answer: B

Rationale: The correct answer is B, Widening pulse pressure. This indicates increasing intracranial pressure (ICP) as it signifies a significant difference between systolic and diastolic blood pressure. A widening pulse pressure is a key sign of impending herniation and requires immediate intervention. A: Gradual increase does not provide a clear indication of acute changes in ICP. C: Rapid drop followed by gradual increase may suggest other conditions and is not specific to increasing ICP. D: Rapid fluctuations may occur in various scenarios and do not specifically point to increasing ICP. In summary, a widening pulse pressure is the most critical and specific indicator of increasing ICP among the choices provided.

Correct Answer: A

Rationale: The correct answer is A: Balance. Loss of ability in balance can indicate various health issues like neurological disorders or musculoskeletal problems. The nurse can assess this by observing the patient's gait, balance while standing, and coordination. Speech (B) relates to communication abilities, judgment (C) involves decision-making skills, and endurance (D) is related to stamina and physical capacity, which are not directly linked to loss of ability.

Correct Answer: C

Rationale: The correct answer is C: Auscultate lung sounds. By auscultating lung sounds, the nurse can assess for changes in breath sounds which can indicate improvement or deterioration in the patient's condition. This helps monitor the effectiveness of therapy for a pneumothorax and chest-drainage system. Palpating for crepitus (A) is not directly related to monitoring therapy effectiveness. Documenting sputum color and amount (B) is important but does not specifically monitor therapy effectiveness. Monitoring suction level (D) is crucial but does not directly assess the patient's response to therapy.

Correct Answer: C

Rationale: Rationale: 1. Pulmonary edema is caused by increased hydrostatic pressure in the pulmonary circulation. 2. Elevated left ventricular end-diastolic pressure signifies heart failure, a common cause of pulmonary edema. 3. A rise in pulmonary venous pressure is a consequence of increased hydrostatic pressure. Therefore, all three alterations (A, B, D) are characteristic of pulmonary edema. Option C is correct. Choices A, B, and D are incorrect because they are all individually associated with pulmonary edema and collectively represent the condition.

Correct Answer: C

Rationale: The correct answer is C: Implementation. In the nursing process, implementation involves carrying out the care plan, interventions, and education that were determined during the planning phase. Providing education to a client about the importance of adhering to prescribed medications falls under this phase as it involves putting the plan into action to promote positive health outcomes. Assessment (A) involves collecting data about the client's condition, Planning (B) involves developing a care plan based on the assessment findings, and Evaluation (D) involves assessing the effectiveness of the interventions implemented.

Correct Answer: B

Rationale: The correct answer is B: Respiratory acidosis. Aspirin can lead to respiratory acidosis due to its effect on the respiratory center in the brainstem. It causes hyperventilation, leading to respiratory alkalosis initially, followed by respiratory acidosis as compensation mechanism fails. Weight gain is not a typical adverse reaction of aspirin. Fine motor tremors are not associated with aspirin therapy. Bilateral hearing loss is a rare but serious side effect of aspirin overdose, not prolonged therapy.

Correct Answer: A

Rationale: The correct answer is A: Urinary output of 30 ml in an hour. Adequate tissue perfusion is best indicated by a sufficient urinary output, as it demonstrates proper kidney perfusion and function. A low urinary output may suggest inadequate perfusion. Explanation for other choices: B: Central venous pressure reading of 2 cm H20 is not a reliable indicator of tissue perfusion to vital organs. C: Pulse rates alone are not enough to indicate tissue perfusion as they can be influenced by various factors. D: Blood pressure readings alone may not accurately reflect tissue perfusion, especially in the context of fluid replacement therapy.

Correct Answer: A

Rationale: The correct answer is A because post-kidney transplant patients are at high risk for fluid and electrolyte imbalances due to the impact of the surgery on renal function. The nurse should assess for signs of fluid overload or depletion and monitor electrolyte levels closely. Choice B, hepatotoxicity, is less immediate and not directly related to kidney transplant. Choice C, infection, is important but not the immediate priority. Choice D, respiratory complications, are also significant but not the most immediate concern post-kidney transplant.

Correct Answer: A

Rationale: The correct answer is A: after the surgery, bleeding is normal. This is because after a TURP procedure, it is common for some bleeding to occur, leading to blood clots in the urine bag. The surgical site undergoes trauma, causing bleeding as a part of the healing process. Choice B is incorrect because while irrigation may be done post-surgery, blood clots in the urine bag are expected due to the surgery itself, not just irrigation. Choice C is incorrect as it is normal for some bleeding to occur after TURP, and immediate physician intervention is not necessary unless excessive bleeding is observed. Choice D is incorrect as tugging on the catheter may cause bleeding, but in this case, the presence of blood clots is likely due to the surgery itself, not catheter irritation.