Rationale for Correct Answers:

• Constipation: Constipation is a common side effect of opioids like oxycodone due to reduced gastrointestinal motility. This risk is heightened in postoperative clients with decreased mobility and altered routines.
• Oxycodone prescription: The prescribed oxycodone every 3 hours PRN increases the likelihood of opioid-induced constipation. Regular opioid use without a bowel regimen can result in significant discomfort or ileus.

Rationale for Incorrect Answers:

• Dysrhythmias: Although the potassium is at the low-normal end (3.6 mEq/L), it does not yet pose a significant risk for dysrhythmias in a stable client without cardiac history or other electrolyte disturbances.
• Hypoglycemia: The casual glucose level of 120 mg/dL is within normal range and does not indicate a risk for hypoglycemia. There’s no diabetic medication involved that would lower blood glucose unexpectedly.
• Hypovolemia: The client has a steady IV fluid infusion, a dry and intact surgical dressing, and no clinical signs of fluid loss. These findings do not support a risk of hypovolemia at this time.
• Impaired circulation: The neurovascular check reveals normal findings: warm toes, intact movement and sensation, and strong pedal pulses. These results suggest adequate perfusion, not impaired circulation.

• Neurovascular check: Normal neurovascular status (warm toes, movement and sensation intact, 2+ pulses) reflects healthy circulation post-surgery and does not correlate with any acute complications.
• Potassium level: Although 3.6 mEq/L is at the lower end of the normal range, it is still adequate and not linked to any current complications like dysrhythmias without other triggers.
• Glucose level: A casual glucose of 120 mg/dL is not clinically concerning and falls within expected limits. It does not suggest hypo- or hyperglycemia in a non-diabetic postoperative patient.
• Femur dressing: The dry and intact dressing indicates that the surgical site is not actively bleeding or infected. It does not signify any increased risk for a complication such as hypovolemia or impaired healing.

Rationale for Correct Answers:

• Client has a 2.5 cm (1 in) x 3 cm (1.2 in) stage 3 pressure injury on left heel: The wound has increased in size from 2.0 cm to 2.5 cm, indicating worsening tissue damage. Progression in wound size suggests ineffective treatment and warrants reassessment of the care plan.
• Increased redness at wound borders: New or worsening erythema around the wound border is a sign of local infection or inflammation. This finding suggests that the wound environment may be contaminated or inflamed.
• Purulent drainage noted: The presence of thick, colored exudate indicates bacterial infection at the wound site. This type of drainage typically requires culture, new dressing orders, and possibly antibiotics.
• Temperature 38.9°C (102°F): This elevated temperature indicates a febrile response, often associated with systemic infection. The fever, along with local wound signs, may point to cellulitis or sepsis risk.
• WBC 12,000/mm³: A white blood cell count above the normal range reflects systemic inflammation or infection. When coupled with fever and purulence, this reinforces the need for urgent evaluation and treatment.

Rationale for Incorrect Choices:

• BP 118/56 mm Hg: This minimal change in blood pressure from 128 to 118, is not a primary indicator of a problem requiring immediate "further action" in the context of the other, more striking findings.
• Pulse oximetry 95% on room air: This oxygen level is within the normal range and indicates adequate gas exchange. It does not point to respiratory distress or infection-related hypoxia.
• Hgb 12 g/dL and Hct 38%: Both values are within the reference range for women and do not indicate anemia or bleeding. They are not relevant to infection progression or pressure injury management.

Rationale for Correct Answers:

• Lithium toxicity: The client’s lithium level is 1.8 mEq/L, which exceeds the therapeutic range of 0.8 to 1.2 mEq/L. Combined with symptoms like diarrhea, vomiting, coarse tremors, confusion, and ataxia, this strongly suggests lithium toxicity, a medical emergency that requires immediate intervention.
• Hypothyroidism: The thyroid profile shows low T3 (71 ng/dL) and free T4 (0.6 ng/dL), along with low-normal TSH (0.3 mu/mL). These values are consistent with hypothyroidism, which can be a side effect of long-term lithium use. Symptoms such as lethargy and disorientation may also reflect thyroid dysfunction.

Rationale for Incorrect Choices:

• Hyperglycemia: The glucose level is 100 mg/dL, which is within the normal reference range. The client has no symptoms of hyperglycemia such as polyuria, polydipsia, or blurred vision.
• Acute kidney injury: The client’s BUN (18 mg/dL) and creatinine (0.9 mg/dL) are within normal limits, indicating that kidney function is preserved at this time and does not meet the criteria for acute kidney injury.

A. Measles, mumps, rubella (MMR): MMR is routinely given at 12 to 15 months of age as part of the standard childhood immunization schedule. At 1 year old, the child’s immune system is developed enough to respond effectively to this live attenuated vaccine.

B. Diphtheria, tetanus, and acellular pertussis (DTaP): The DTaP vaccine is given in a series, with doses at 2, 4, 6, and 15–18 months, and a booster at 4–6 years. At 1 year old, the child is due for the fourth dose between 15–18 months, so it may be administered if the child is nearing that window, depending on prior schedule adherence.

C. Varicella (VAR): The varicella vaccine is recommended for children starting at 12 to 15 months of age. Since the child is now 1 year old, this vaccine is appropriate and helps prevent chickenpox, a highly contagious viral illness.

D. Rotavirus (RV): The final dose of the rotavirus vaccine series must be administered by 8 months of age. A 1-year-old is past the recommended age window for rotavirus vaccination, and administering it now is not recommended.

E. Human papillomavirus (HPV): The HPV vaccine is not given to children as young as 1 year old. It is typically administered starting at 11 to 12 years of age to prevent HPV-related diseases such as cervical and other cancers.

A. Increased heart rate: Tachycardia occurs as a compensatory mechanism in fluid overload due to the heart working harder to circulate the excess volume. The increased preload stretches the myocardial fibers, triggering a higher heart rate to maintain effective perfusion.

B. Increased blood pressure: Excess fluid volume raises intravascular pressure, leading to hypertension. The increased circulating volume causes elevated preload and afterload, resulting in increased cardiac output and higher blood pressure readings.

C. Increased respiratory rate: Fluid overload can lead to pulmonary congestion or edema, impairing gas exchange. The body compensates by increasing the respiratory rate to improve oxygenation and reduce carbon dioxide levels, especially if dyspnea is present.

D. Increased hematocrit: Hematocrit levels typically decrease in fluid overload due to hemodilution. The plasma volume expands relative to red blood cell concentration, leading to a dilutional effect that lowers hematocrit levels.

E. Increased temperature: Fever is not a typical finding in fluid overload and is more indicative of infection or inflammation. In fluid overload, temperature generally remains within normal limits unless an underlying infectious process is also present.

Rationale for Correct Answers:

• Heart Failure: The client’s elevated BNP (352 pg/mL), cardiomegaly, bibasilar congestion on chest x-ray, and use of loop diuretics suggest volume overload consistent with heart failure. Tachycardia and elevated blood pressure also support this diagnosis in the elderly client.
• Elevate the head of the bed: Elevating the head of the bed helps reduce pulmonary congestion by improving ventilation and easing the work of breathing, which is crucial in clients with fluid overload and pleural congestion.
• Encourage intake of low sodium diet: Sodium restriction helps control fluid retention and blood pressure, which are key components in managing heart failure and preventing exacerbations.
• Urinary output: Monitoring urinary output helps evaluate the effectiveness of diuretic therapy and assess kidney perfusion, both essential in managing fluid volume status in heart failure.
• Blood pressure: Blood pressure monitoring is necessary to assess cardiovascular stability and the response to medications like carvedilol and furosemide, especially in elderly patients at risk for hypotension or rebound hypertension.

Rationale for Incorrect Choices:

• Anemia: The hemoglobin and hematocrit levels are within normal range, making anemia unlikely. No signs like pallor or fatigue are reported.
• Type 2 diabetes mellitus: HbA1c (6.2%) and glucose (102 mg/dL) are well-controlled. Although the client is on metformin, there’s no indication of acute complications needing intervention.
• Urinary tract infection: The urinalysis is normal with no presence of leukocyte esterase, nitrites, WBCs, or RBCs, making a UTI unlikely.
• Teach the client signs of hyperglycemia: This is not a priority right now since the client’s blood glucose and HbA1c are within normal limits, indicating well-controlled diabetes.
• Assess feet for sensation: While this is an appropriate action for long-term diabetes care, it is not directly related to the client’s current acute issue of heart failure.
• WBC count: The WBC count is normal, and there is no sign of infection. Monitoring WBC would not provide meaningful data related to heart failure progression.
• Finger prick blood glucose level: This is not a priority given stable glucose levels; other parameters like fluid balance and BP are more critical for tracking heart failure progress.
• Hemoglobin: Hemoglobin is within normal range and not relevant for tracking heart failure status in this case.

• Ambulate in hallway with supervision: While mobility helps prevent complications, it is not a priority during an acute pain crisis. The client is in severe pain and resisting movement, so ambulation would be inappropriate until pain is better controlled.
• Ketorolac IV for pain: Ketorolac, a nonsteroidal anti-inflammatory drug (NSAID), is commonly used adjunctively in sickle cell crises for its analgesic and anti-inflammatory effects, especially when opioids alone are ineffective.
• Ice packs to affected area: Cold therapy causes vasoconstriction, which can worsen sickling and ischemia in clients with sickle cell disease. Heat therapy is preferred for promoting circulation during a vaso-occlusive episode.
• Meperidine for pain: Meperidine is avoided in sickle cell disease due to the risk of neurotoxicity (e.g., seizures) from its metabolite, normeperidine, especially with repeated doses or in renal impairment.
• Intravenous fluids (IVF) at maintenance rate: Hydration is critical in sickle cell crises to reduce blood viscosity and prevent further sickling. IV fluids are a standard component of treatment during acute pain episodes.
• Oxygen 2 L/min via nasal cannula: The client is not hypoxic and has a normal respiratory rate (18 / min), and routine oxygen is not required unless oxygen saturation decreases. Overuse of oxygen can suppress erythropoiesis in chronic use.

Rationale for Correct Answer:

• Dehydration: The client has had 4 loose stools within 6 hours, which leads to excessive fluid loss. Despite a normal gastric residual and patent G-tube, the presence of fever, chills, and diaphoretic skin further supports fluid depletion. Hyperactive bowel sounds and flushed skin are also consistent with volume loss due to gastrointestinal losses.

Rationale for Incorrect Answers:

• Infection: Although the client has a mild fever and chills, the skin around the G-tube is clean and intact with no localized signs of infection. Lungs are clear, and there is no report of purulent drainage or abnormal WBCs to support active infection.
• Tube displacement: The G-tube is documented as patent with low gastric residuals and no discomfort or signs of misplacement, making displacement unlikely.
• Absent gag reflex: There is no documentation suggesting swallowing issues, aspiration risk, or neurological impairment. The client is alert and oriented, suggesting intact protective reflexes.
• Fluid overload: The client shows no signs of fluid retention like crackles in lungs, edema, or hypertension beyond mild systolic elevation. The presence of diarrhea and diaphoretic skin suggests fluid loss rather than overload.

Rationale for Correct Answers:

• Metabolic acidosis: The client’s ABG shows a low pH of 7.33 and bicarbonate (HCO3) of 19 mEq/L, indicating primary metabolic acidosis, likely due to prolonged diarrhea and bicarbonate loss through the GI tract.
• Hypernatremia: Serum sodium is elevated at 149 mEq/L, likely resulting from fluid loss due to persistent diarrhea and poor fluid intake, which concentrates serum sodium.

Rationale for Incorrect Answers:

• Hypermagnesemia: The magnesium level is 1.8 mEq/L, which is within the normal range. There is no indication of magnesium excess, and the client has not received supplements or renal impairment.
• Hypervolemia: The client shows signs of volume depletion, including hypotension, dry mucous membranes, and poor skin turgor. Urine output is low, supporting fluid loss rather than overload.
• Hyperkalemia: Although potassium is at the upper normal limit (5.0 mEq/L), there’s no current evidence of cellular lysis, renal failure, or acidosis severe enough to cause clinically significant hyperkalemia.
• Metabolic alkalosis: The client’s ABG values do not support metabolic alkalosis. There is no vomiting or gastric suction to suggest bicarbonate retention; instead, the client has diarrhea leading to acid loss.

Rationale for Correct Findings:

• Temperature 35.3° C (95.5°F): A drop in body temperature is common in the final hours as the body loses its ability to regulate temperature. This change often indicates reduced circulation and metabolism due to impending death.
• Heart rate 42/min: Bradycardia suggests reduced cardiac output and diminished perfusion, common in end-of-life stages. This slowing of the heart is often a precursor to cessation of cardiac activity.
• Blood pressure 62/— mm Hg palpated: A non-measurable diastolic pressure with only palpable systolic pressure signals profound hypotension. This is consistent with the circulatory collapse observed in actively dying patients.
• Client does not arouse to verbal, tactile, or painful stimulation: Unresponsiveness to all forms of stimuli is a key sign of active dying and declining neurological function. This change often occurs shortly before death.
• Cheyne-Stokes breathing, noisy respirations: This irregular breathing pattern with periods of apnea and deep breaths signals neurological decline. Noisy respirations, often called the "death rattle," result from loss of airway clearance ability.
• Family reports no urine output in last 4 hr: Oliguria progressing to anuria reflects kidney shutdown, a critical sign of multi-organ failure. This is a frequent finding in the final phase of life.

Rationale for Incorrect Findings:

• Skin intact: Intact skin indicates preserved skin integrity and absence of pressure injury or breakdown. While reassuring for comfort, this finding does not indicate death is imminent.
• Bowel sounds in all four quadrants: Presence of bowel sounds suggests that some gastrointestinal activity remains. Bowel sounds alone are not reliable indicators of whether a client is actively dying and can persist late into the dying process.