Why should the nurse closely monitor a client to ensure that the venous access device remains in the vein during a transfusion?

Correct Answer: D

Rationale: Keeping the venous access device securely in the vein during a transfusion is important to minimize the risk of localized edema embolism. If the device dislodges and infiltrates into surrounding tissues, it can lead to localized swelling, pain, and potential complications such as tissue damage. Monitoring ensures proper placement and function of the device, reducing the risk of complications related to dislodgment.

Correct Answer: C

Rationale: In a patient with hyperglycemic, hyperosmolar nonketotic coma (HHNK), the high blood glucose levels lead to osmotic diuresis, causing excessive urination and subsequent dehydration. Dehydration can manifest as symptoms such as dry mucous membranes, poor skin turgor, decreased urine output, increased heart rate, and low blood pressure. Therefore, the nurse should expect to find signs of severe dehydration in a patient with HHNK coma. The other options listed are not typical assessment findings associated with HHNK coma.

Correct Answer: C

Rationale: Reducing evening fluids and using positive reinforcement (reward system) are effective and developmentally appropriate strategies.

Correct Answer: D

Rationale: The first action the nurse should take is to check for neurologic status. This is essential in assessing the patient's level of consciousness, orientation, motor function, and pupil responses. It helps determine if the patient is experiencing neurological issues such as a stroke, which would require immediate medical attention. Checking neurologic status is a priority because it guides the nurse in identifying the next steps for the patient's care.

Correct Answer: C

Rationale: The nurse can help monitor the effectiveness of therapy for a patient with a pneumothorax and chest drainage system by auscultating lung sounds. Auscultation can provide information about the air movement within the lungs and any changes in lung sounds, such as decreased or absent breath sounds on the affected side, which may indicate improvement or deterioration in the patient's condition. By regularly assessing lung sounds, the nurse can track the progress of the therapy and make informed decisions about the patient's care and treatment plan. Palpating for crepitus, documenting sputum characteristics, and monitoring suction levels are important aspects of care but are not specifically focused on assessing the effectiveness of therapy for a pneumothorax.