Which of the following would have the highest priority in septic shock?

Correct Answer: C

Rationale: In the context of septic shock, monitoring airway, breathing, and circulation (ABC) would have the highest priority. This is because septic shock is a life-threatening condition characterized by a systemic inflammatory response to infection, leading to severe hypotension and inadequate tissue perfusion. Monitoring ABC ensures that the patient's vital functions are maintained and supported, which is crucial in stabilizing their condition and preventing further deterioration. Monitoring temperature (Option A) is important in septic shock to assess for fever, a common symptom, but it is not the highest priority compared to ensuring the patient's airway, breathing, and circulation are intact. Monitoring pupillary reaction (Option B) is more relevant in neurological assessments and is not as critical in the immediate management of septic shock. Monitoring ANA and RF levels (Option D) is not a priority in the acute phase of septic shock. These laboratory tests are more related to autoimmune conditions and would not guide the immediate resuscitative actions needed in septic shock. In an educational context, understanding the priority of interventions in managing septic shock is crucial for nurses and healthcare providers in providing timely and effective care to critically ill patients. Emphasizing the ABCs as the foundation of patient assessment and care in emergencies like septic shock reinforces the principles of prioritizing interventions based on the patient's immediate needs to achieve the best outcomes.

Correct Answer: B

Rationale: The correct answer is option B) You breathe through a mouthpiece into a spirometer until all air in your lungs is expelled; then you take a deep breath through the mouthpiece. This is done three times and a computer calculates the capacity of your lungs. This answer is correct because it accurately describes the procedure of a pulmonary function test (PFT). During a PFT, the individual breathes into a spirometer to measure lung function parameters such as lung capacity, volume, and flow rates. The process involves both exhalation and inhalation maneuvers to assess different aspects of lung function. Option A is incorrect because it oversimplifies the procedure by stating that you simply breathe into a spirometer to measure lung capacity without mentioning the specific steps involved in a PFT. Option C is incorrect because it only mentions the use of a computer to measure volume and vital capacity without detailing the actual process of performing a PFT. Option D is incorrect because it describes a method that is not used in pulmonary function testing. Inserting a tube into the lungs while the individual is asleep is not a standard or safe practice for conducting PFTs. In an educational context, understanding how a pulmonary function test is performed is crucial for healthcare providers to accurately interpret the results and make appropriate clinical decisions for patients with respiratory conditions. Proper knowledge of PFT procedures ensures accurate assessment of lung function and effective management of respiratory disorders.

Correct Answer: C

Rationale: In the case of aortic insufficiency, after aortic valve repair, the physician would likely prescribe Heparin. Heparin is an anticoagulant medication that helps prevent blood clot formation post-surgery. This is crucial as patients undergoing valve repair are at risk for clot formation due to changes in blood flow dynamics. The other options (Ativan, Haldol, Thorazine) are not appropriate in this context. Ativan and Haldol are used for anxiety and psychiatric conditions, while Thorazine is an antipsychotic medication. These medications are not indicated for the treatment of aortic insufficiency or post-surgical management. From an educational perspective, understanding the rationale behind post-surgical medication choices is essential for nursing students and healthcare professionals caring for patients with cardiovascular conditions. Knowing the appropriate medications and their indications can help ensure optimal patient outcomes and prevent complications post-surgery.

Correct Answer: C

Rationale: In the context of adult medical surgical education, providing instructions to patients at risk for testicular cancer is crucial for early detection and prevention. The correct answer, option C - Testicular self-exam, is important because it empowers the patient to perform regular self-assessments, leading to early identification of any abnormal changes in the testicles. This proactive approach can significantly increase the chances of detecting testicular cancer at an early stage, improving treatment outcomes and prognosis. Option A is incorrect because there is no evidence to suggest that restricting potassium, phosphate, sodium, or protein in the diet can prevent or reduce the risk of testicular cancer. Option B is also incorrect as self-catheterization of ileal reservoir is not a recommended practice for testicular cancer risk reduction. Option D is incorrect as a change in color of urine is not an expected sign of testicular cancer and should not be communicated as a typical symptom to the patient. Educationally, emphasizing the importance of regular testicular self-exams and providing clear instructions on how to perform them can empower patients to take an active role in their health and well-being. Encouraging open communication about any concerns or changes observed during self-exams can facilitate early intervention and prompt medical evaluation if needed. By educating patients on self-care practices specific to testicular health, healthcare providers can contribute to better patient outcomes and overall health literacy.

Correct Answer: D

Rationale: The correct answer is D) practice good dental hygiene and report gum swelling or bleeding. Phenytoin sodium (Dilantin) is known to cause gingival hyperplasia, a common side effect characterized by swollen, bleeding gums. By practicing good dental hygiene and promptly reporting any gum issues to their healthcare provider, patients can prevent or manage this adverse effect. Option A) avoid crowds and obtain an annual influenza vaccination is incorrect because it does not directly relate to preventing the adverse effect of phenytoin sodium. Option B) drink at least 2 L of fluids daily, including 8 to 10 glasses of water is incorrect as it is a general recommendation for hydration and not specific to managing the side effects of phenytoin. Option C) eat a potassium-rich, low-sodium diet is incorrect as it is not directly related to preventing the gum-related side effects of phenytoin sodium. In an educational context, understanding the side effects of medications and how to manage them is crucial for nurses and healthcare professionals to provide comprehensive care to patients. Teaching patients about the potential side effects of phenytoin, such as gingival hyperplasia, and the importance of good dental hygiene empowers them to take an active role in their health and well-being.