Which sign might a nurse observe in a client with a high ammonia level?

Correct Answer: A

Rationale: The correct answer is A: coma. High ammonia levels can lead to hepatic encephalopathy, causing impaired brain function and potentially leading to coma. Edema (B) is typically associated with fluid retention, not high ammonia levels. Hypoxia (C) is a condition of low oxygen levels, not directly related to high ammonia levels. Polyuria (D) is excessive urination, which is not a common sign of high ammonia levels.

Correct Answer: B

Rationale: The correct answer is B: Vitamin B12. Strict vegetarians, especially those who exclude all animal products, are at risk of Vitamin B12 deficiency as it is primarily found in animal products. Vitamin C (A) deficiency is more common in those with poor fruit and vegetable intake. Vitamin E (C) deficiency is rare and usually seen in individuals with specific medical conditions. Magnesium (D) deficiency can occur in individuals with poor dietary intake or certain medical conditions, but it is not the primary concern for strict vegetarians.

Correct Answer: D

Rationale: The correct answer is D because when a client experiences an allergic reaction to a medication, the nurse should monitor for signs of infection as allergic reactions can sometimes lead to secondary infections. By closely monitoring the client for signs of infection, the nurse can promptly intervene and provide appropriate treatment. A: Discontinuing the medication is important but not the immediate priority when dealing with an allergic reaction. B: Notifying the healthcare provider is important, but monitoring for signs of infection takes precedence in this situation. C: Administering antihistamines may help with allergic symptoms but does not address the potential risk of secondary infection.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. This is the most important intervention for a client with an obstructed airway because it helps to ensure that the patient is receiving adequate oxygen supply to prevent hypoxia. Oxygen therapy can help maintain oxygen saturation levels and support proper gas exchange in the lungs. Monitoring respiratory rate (B) is important but not as critical as ensuring oxygen supply. Administering morphine (C) is contraindicated as it can depress respiratory function further. Administering fluids (D) is not the priority in managing an obstructed airway.

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. When a client with asthma develops wheezing, the primary action is to administer bronchodilators to help dilate the airways and improve breathing. This helps relieve the symptoms of wheezing and prevent further complications. Providing pain relief (Choice B) is not the primary action for wheezing in asthma. Encouraging deep breathing (Choice C) may worsen the wheezing in an asthma attack. Performing chest physiotherapy (Choice D) is not the first-line treatment for wheezing in asthma.

Correct Answer: A

Rationale: The correct answer is A: Monitor aPTT levels. This is crucial in intravenous heparin therapy to ensure the therapeutic range is maintained for anticoagulation without causing bleeding. Monitoring aPTT helps adjust heparin dosage to prevent clot formation or excessive bleeding. B: Monitoring for bleeding is important but not the most important action compared to monitoring aPTT levels for appropriate dosing. C: Checking platelet count is important for some anticoagulants like heparin, but aPTT monitoring is more directly related to heparin's anticoagulant effect. D: Administering a heparin antidote (protamine sulfate) is necessary in case of heparin overdose or in emergency situations but is not the primary action in routine care.

Correct Answer: B

Rationale: The correct answer is B: increased fibrinogen. In DIC, there is consumption of coagulation factors leading to decreased fibrinogen levels. Heparin therapy helps by inhibiting further thrombus formation, allowing the body to replenish fibrinogen levels. Increased fibrinogen indicates a positive response. Incorrect choices: A) increased platelet count is not specific to Heparin therapy in DIC, C) decreased fibrin split products indicate ongoing coagulation, not a positive response, and D) decreased bleeding is a general response and not specific to Heparin therapy in DIC.

Correct Answer: B

Rationale: The correct action for a client with DVT in the leg is to apply compression and elevate the leg (Choice B). Compression helps prevent blood clots from moving and causing further complications. Elevating the leg reduces swelling and improves blood flow. Choice A is incorrect because applying heat can actually worsen DVT by promoting inflammation and increasing blood flow. Choice C is incorrect as massage can dislodge blood clots and lead to serious complications like pulmonary embolism. Choice D is incorrect as massaging the leg can be dangerous in DVT as mentioned before.

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. In an acute asthma attack, the priority is to open the airways and improve breathing. Bronchodilators work quickly to relax the muscles around the airways, allowing the client to breathe easier. Corticosteroids are used for long-term control, not immediate relief. Oxygen therapy may be needed if the client's oxygen levels are low. Pain medication is not indicated for an acute asthma attack as the primary issue is airway constriction, not pain. Administering bronchodilators first helps address the immediate breathing difficulty in an asthma attack.