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: Place in a safe environment. This is the first priority to ensure the safety of the confused post-operative client. Placing the client in a safe environment prevents harm from falls or accidents. Reorienting the client (choice A) can come after ensuring safety. Administering pain relief (choices C and D) should be done based on assessment but is not the first priority when the client is confused.

Correct Answer: B

Rationale: The correct answer is B: Tenderness, warmth, and swelling at the site. Post-operative wound infection often presents with localized tenderness, warmth, and swelling due to inflammation and immune response. Redness, heat, and purulent drainage (choice A) can also indicate infection but are not specific to wound infections. Excessive swelling and redness (choice C) may be present in inflammatory responses but do not specifically point to an infection. Fever, chills, and nausea (choice D) can be systemic signs of infection but are not specific to wound infections. Tenderness, warmth, and swelling are more indicative of a localized wound infection.

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: A

Rationale: The correct answer is A: Administer glucose. The nurse's first action in treating hypoglycemia is to increase the client's blood glucose levels to prevent further complications. Administering glucose helps quickly raise blood sugar levels, addressing the immediate issue. Options B, C, and D are incorrect as administering insulin would further decrease blood sugar levels, administering oxygen is not the primary intervention for hypoglycemia, and administering antipyretics is used for reducing fever, not treating hypoglycemia.

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: A

Rationale: The correct answer is A: Assess airway. In caring for a client with a traumatic head injury, the first priority is to ensure there is a clear airway to maintain oxygenation and ventilation, which is crucial for brain function. If the airway is compromised, it can lead to hypoxia and further brain damage. Providing pain relief (B) is important but not the immediate priority. Monitoring intracranial pressure (C) is essential but comes after ensuring a patent airway. Maintaining a quiet environment (D) can help reduce stimulation, but it is not as critical as assessing the airway for immediate intervention.

Correct Answer: A

Rationale: The proper hand position for chest percussion is to cup the hands, creating a hollow space to allow for effective transmission of percussion vibrations. Cupping the hands helps to produce the desired percussion sound and ensures proper force distribution. Using the side of the hands (B) may not provide enough surface area for effective percussion. Flattening the hands (C) may not generate the desired percussive effect, and spreading the fingers of both hands (D) can result in uneven force application. Therefore, cupping the hands is the most appropriate hand position for chest percussion.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. In the case of shock, the first priority is to restore circulating volume to improve tissue perfusion. IV fluids help increase blood volume and improve oxygen delivery to vital organs, addressing the underlying cause of shock. Choice B (Administer oxygen) can be important but is not the first priority. Choice C (Place the client in a supine position) may worsen certain types of shock. Choice D (Monitor blood pressure) is important but not the first action needed to address shock. Administering IV fluids promptly can stabilize the client's condition and prevent further deterioration.