Correct Answer: C

Rationale: The nurse would identify platelets at 115,000/ul as an abnormal finding because it is below the normal range of 150,000-450,000/ul. Low platelet count can lead to increased bleeding risk. RBC count and hematocrit levels are within normal ranges, making them normal findings. Option D is incorrect as platelets are abnormal.

Correct Answer: C

Rationale: The correct answer is C: Drug Compliance. After a CVA (stroke), it is crucial for Mr. Dela Isla to understand and adhere to his prescribed medications. Medications help prevent further strokes and manage underlying conditions. Drug compliance ensures optimal treatment outcomes. Emergency Numbers (A) are important but not the priority post-stroke. Relaxation techniques (B) may be helpful but not as critical as medication adherence. Dietary prescription (D) is important but not as urgent as drug compliance in this scenario.

Correct Answer: A

Rationale: The correct answer is A because a normal respiratory rate for an adult is typically between 12-20 breaths per minute. A respiratory rate of 18 falls within this range, indicating adequate respiratory function. Choice B is incorrect because an oxygen saturation of 91% is below the normal range of 95-100%, suggesting potential respiratory insufficiency. Choice C is incorrect as frank blood suction from the tube indicates a serious issue such as bleeding, not adequate respiratory condition. Choice D is also incorrect as the presence of a moderate amount of tracheobronchial secretions may indicate a respiratory infection or other respiratory issue, not necessarily adequate respiratory condition.

Correct Answer: D

Rationale: The correct answer is D: "I will have my potassium level checked." Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Monitoring potassium levels is crucial to prevent complications such as cardiac arrhythmias. A: Monitoring urine sodium is not typically necessary for furosemide therapy. B: Prothrombin time monitoring is unrelated to furosemide therapy. C: Monitoring calcium levels is not directly affected by furosemide use. In summary, monitoring potassium levels is essential due to the potential for hypokalemia with furosemide, while the other options are not directly relevant to this medication.

Correct Answer: B

Rationale: The correct response is B: Notify the physician immediately and expect an order for factor VIII. In a patient with hemophilia A, which is a deficiency of clotting factor VIII, bleeding into a joint can lead to serious complications. The nurse should notify the physician promptly because the patient may need factor VIII replacement therapy to stop the bleeding and prevent further damage. This is a medical emergency requiring timely intervention. Choices A, C, and D are incorrect: A: Palpating the elbow could exacerbate the bleeding and cause further damage. C: Ordering an x-ray would delay the crucial factor VIII replacement therapy needed to manage the bleeding. D: Applying heat can increase blood flow to the joint, worsening the bleeding.