Correct Answer: A

Rationale: Clear drainage from the surgical site may indicate a cerebrospinal fluid leak, requiring immediate provider notification. Pain, mild fever, and normal heart rate are expected.

Correct Answer: C

Rationale: Monitoring for muscle weakness, which may indicate hypokalemia, is critical, as furosemide is a loop diuretic that can cause potassium loss, increasing the risk of arrhythmias in heart failure clients.
Choice A is wrong because clients with heart failure should limit sodium intake to reduce fluid retention, not increase it, to prevent exacerbation of heart failure.
Choice B is wrong because taking furosemide at bedtime is not advised; it should be taken in the morning to avoid nocturia and disrupted sleep due to its diuretic effect.
Choice D is wrong because increasing fluid intake is not recommended for heart failure clients, as it can worsen fluid overload; fluid intake should be guided by the provider based on the client's condition.

Correct Answer: B

Rationale: Monitoring aPTT (activated partial thromboplastin time) is essential for clients receiving heparin, as it measures the therapeutic effect of heparin on the intrinsic clotting pathway, ensuring the dose is within the therapeutic range (1.5-2.5 times the baseline).
Choice A is incorrect because INR is used to monitor warfarin, not heparin.
Choice C is incorrect because, while platelet count should be monitored to detect heparin-induced thrombocytopenia, aPTT is the primary test for heparin therapy.
Choice D is incorrect because heparin does not directly affect potassium levels; electrolyte monitoring is not a priority.

Correct Answer: D

Rationale: Absence of breath sounds on the affected side is a critical finding that may indicate a pneumothorax, lung collapse, or chest tube malfunction, requiring immediate reporting to the provider.
Choice A is incorrect because tidaling (fluctuations) in the water seal chamber is a normal finding, indicating the chest tube is functioning and the lung is re-expanding.
Choice B is incorrect because continuous bubbling in the suction control chamber is expected when suction is applied, as it regulates the amount of suction.
Choice C is incorrect because drainage of 50 mL/hr is within the expected range for the first 24-48 hours post-thoracotomy and does not require immediate reporting unless excessive (>100 mL/hr).

Correct Answer: B

Rationale:
Choice A is wrong because decreasing insoluble fiber intake can worsen constipation. Insoluble fiber adds bulk to the stool and helps it pass more easily through the colon. Clients who take opioid medications should increase their intake of insoluble fiber from sources such as whole grains, fruits, vegetables, nuts, and seeds. Exercise can help stimulate bowel movements and prevent constipation, which is a common side effect of opioid medications. Exercise can also improve blood circulation, reduce stress, and enhance mood, which can benefit clients who have chronic pain.
Choice C is wrong because drinking less water can lead to dehydration and hardening of the stool, which can make it more difficult to pass. Clients who take opioid medications should drink plenty of water to keep the stool soft and moist.
Choice D is wrong because taking a laxative every day can cause dependence, tolerance, and electrolyte imbalance. Laxatives should be used only as a last resort and under the guidance of a health care provider. Clients who take opioid medications should try other methods of preventing constipation first, such as increasing exercise, fiber, and water intake.