With severe diarrhea, electrolytes as well as fluids are lost. What electrolyte imbalance is indicated in Ms. CC's decreased muscle tone and deep tendon reflexes?

Correct Answer: C

Rationale: Hypokalemia is indicated in Ms. CC's decreased muscle tone and deep tendon reflexes. Potassium is an essential electrolyte for muscle function, including maintaining muscle tone and supporting proper nerve conduction for reflexes. When potassium levels are low, it can lead to muscle weakness, decreased muscle tone, and reduced deep tendon reflexes. With severe diarrhea, potassium is often lost along with fluids, leading to a potential electrolyte imbalance such as hypokalemia. Additionally, hypokalemia can cause cardiac arrhythmias, muscle cramps, and fatigue, further supporting the presence of this electrolyte imbalance in Ms. CC.

Correct Answer: A

Rationale: Monitoring daily intake and output is the most reliable method for assessing fluid balance in a patient. By accurately measuring the amount of fluids taken in through foods, drinks, and IV fluids, as well as the amount of fluids eliminated through urine, stool, vomit, and other means, healthcare providers can closely track the body's fluid balance. Discrepancies between intake and output can indicate potential issues such as dehydration or fluid overload. This method provides quantitative data that can guide appropriate interventions and treatment adjustments to maintain the patient's fluid balance within normal limits. While vital signs, daily weight, and skin turgor are also important indicators of fluid status, they may not always provide as specific or accurate information as the direct measurement of intake and output.

Correct Answer: D

Rationale: The last step when inserting an IV cannula is to place a sterile dressing over the insertion site. This helps to protect the site from contamination and reduce the risk of infection. A sterile dressing also helps to maintain the integrity of the insertion site and prevent any foreign materials from entering the wound. Additionally, the dressing provides a barrier between the cannula site and the external environment, promoting healing and reducing the chance of complications.

Correct Answer: C

Rationale: Radiation therapy for lung cancer is typically used with the goal of increasing comfort for the patient by reducing symptoms such as pain, shortness of breath, and coughing. While it may help to shrink tumors and slow the progression of the disease, it is usually not considered a curative treatment for advanced lung cancer. It is important for the patient to have realistic expectations and understand that the goal of radiation therapy is primarily to improve their quality of life and manage symptoms.

Correct Answer: C

Rationale: Bronchiectasis is a condition characterized by the abnormal widening and thickening of the bronchial tubes, leading to a build-up of mucus. One of the common assessment findings in clients with bronchiectasis is the expectoration of small amounts of sputum. This is due to the increased mucus production and impaired clearance from the airways. The sputum may be foul-smelling and may contain pus or blood due to chronic infection and inflammation in the bronchial tubes.