A. The client has hypertension and anuria. Hypertension is not a common feature of postoperative shock. Instead, shock is typically characterized by hypotension due to inadequate perfusion. Anuria, while concerning, is usually a later sign of severe hypovolemia or organ failure rather than an early indicator of shock.
B. The client develops bradycardia and bradypnea. Shock generally triggers a compensatory response, leading to tachycardia as the body attempts to maintain cardiac output. Bradycardia and bradypnea are more commonly associated with conditions such as neurogenic shock or opioid overdose rather than hypovolemic or septic shock, which are more frequent in postoperative settings.
C. The client has hypotension and is confused. Hypotension is a hallmark sign of postoperative shock, often resulting from blood loss, fluid shifts, or sepsis. Confusion occurs due to decreased cerebral perfusion and oxygenation. These symptoms indicate a state of inadequate circulation requiring immediate intervention, making this the most appropriate answer.
D. The client has metabolic alkalosis and warm extremities. Postoperative shock is more commonly associated with metabolic acidosis due to poor tissue perfusion and lactic acid buildup rather than alkalosis. Additionally, warm extremities are typical in early septic shock, whereas most types of shock, such as hypovolemic or cardiogenic shock, lead to cool, clammy skin due to vasoconstriction.

A. Continue to monitor the client's respiratory status. Slow, steady bubbling in the suction control chamber is an expected finding in a closed chest drainage system, indicating that the system is functioning correctly by maintaining negative pressure. There is no immediate cause for concern, so the nurse should continue monitoring the client’s respiratory status to ensure adequate lung expansion and detect any signs of respiratory distress or complications.
B. Clamp the chest tube. Clamping the chest tube is not appropriate in this scenario and can be dangerous. It may cause air or fluid accumulation in the pleural space, leading to a tension pneumothorax. Clamping is only done for specific situations, such as assessing for air leaks or before removing the tube, under direct medical supervision.
C. Check the suction control outlet on the wall. If there were no bubbling in the suction control chamber, checking the suction control outlet might be necessary to ensure the suction is properly set. However, slow, steady bubbling is normal, so there is no need to adjust the suction source.
D. Check the tubing connections for leaks. Checking for leaks is essential if there is continuous bubbling in the water seal chamber, which indicates an air leak. However, bubbling in the suction control chamber is expected when the system is functioning correctly, so this action is unnecessary in this case.

A. Oxygen saturation of 95%. While oxygen saturation has improved after thoracentesis, it is within an acceptable range and does not require immediate intervention. However, continuous monitoring is necessary to detect any decline.
B. Heart rate 110/min and regular. Tachycardia can indicate hypovolemia, respiratory distress, or a developing pneumothorax following the removal of a large amount of pleural fluid. The nurse should assess for additional signs of distress and notify the provider if it persists or worsens.
C. Puncture site dry. A dry puncture site is an expected finding, indicating no active bleeding or fluid leakage from the procedure. This does not require immediate followup.
D. Subcutaneous emphysema.The presence of air under the skin suggests a possible lung puncture or air leak into the subcutaneous tissue. This finding requires immediate assessment to rule out a pneumothorax, which may necessitate further intervention such as chest tube placement.
E. Trachea midline. A midline trachea indicates that there is no significant shift in mediastinal structures, ruling out severe pneumothorax or tension pneumothorax. This is a reassuring finding and does not require urgent action.
F. Decreased lung sounds. A reduction in lung sounds on the affected side can indicate lung collapse, reaccumulation of pleural fluid, or pneumothorax following thoracentesis. This requires immediate followup to assess for respiratory compromise and possible imaging to confirm the underlying cause.

A. Have the client refrain from talking for 24 hr. While the throat may be sore after a bronchoscopy, complete voice rest for 24 hours is not necessary. The client may speak as tolerated once their gag reflex returns.
B. Suction the client’s oropharynx frequently. Routine oropharyngeal suctioning is not recommended unless the client has excessive secretions or airway obstruction. Unnecessary suctioning can cause irritation and discomfort.
C. Irrigate the client’s throat every 4 hr. Throat irrigation is not a standard postbronchoscopy intervention. Instead, throat lozenges or gargling with warm saline may help if the client experiences mild throat discomfort.
D. Withhold food and liquids until the client’s gag reflex returns. This is the most appropriate nursing action. A bronchoscopy involves the use of local anesthesia to numb the throat, which temporarily suppresses the gag reflex. To prevent aspiration, food and fluids should be withheld until the gag reflex has fully returned.

A. Fever. While fever can indicate an underlying infection or inflammatory process, it is not a hallmark feature of idiopathic thrombocytopenic purpura (ITP). ITP is primarily a disorder of platelet destruction rather than an infectious or febrile illness. However, if the patient develops a fever, it may warrant investigation for secondary infections, especially if immunosuppressive therapy (e.g., corticosteroids) is being used.
B. Fatigue. Fatigue can occur in ITP due to chronic bleeding leading to anemia, but it is not the most critical parameter to monitor. While some patients with ITP experience fatigue due to immune dysregulation or blood loss, it is a nonspecific symptom that does not directly guide clinical management.
C. Ecchymosis. This is the most appropriate manifestation to monitor, as ITP is characterized by thrombocytopenia, leading to an increased risk of spontaneous bleeding and bruising (ecchymosis). Patients often present with petechiae, purpura, or mucosal bleeding (e.g., epistaxis, gingival bleeding). Close monitoring for worsening bruising, prolonged bleeding, or signs of internal hemorrhage (e.g., hematuria, melena) is essential for managing ITP effectively and determining treatment response.
D. Elevated WBC. ITP is an autoimmune condition primarily affecting platelet levels and does not directly cause an elevated white blood cell (WBC) count. An increased WBC count may suggest an infection, inflammation, or hematologic malignancy, but it is not a characteristic feature of ITP. Monitoring platelet counts, bleeding tendencies, and potential adverse effects of immunosuppressive therapy is more clinically relevant.

A. Increase raw produce in the client's diet. Clients with an absolute neutrophil count (ANC) <1,000/mm³ are at high risk for infection due to neutropenia. Raw produce, including fruits and vegetables, may contain bacteria or fungi that could lead to infections. These clients should follow a neutropenic diet, which includes cooked foods and avoids raw or undercooked items.
B. Limit visitors to healthy adults. This is the most appropriate intervention. Clients with severe neutropenia (ANC <1,000/mm³) have a significantly weakened immune system and are highly susceptible to infections. Restricting visitors to only healthy adults reduces the risk of exposure to pathogens. Additionally, visitors should follow proper hand hygiene and wear a mask if necessary to prevent transmission of infectious agents.
C. Instruct the client to floss his teeth daily. Flossing can cause minor gum trauma, increasing the risk of bacterial entry and infection in neutropenic clients. Instead of flossing, the client should use a soft toothbrush and practice gentle oral hygiene to minimize the risk of oral mucosal injury and subsequent infection.
D. Take the client's rectal temperature each day. Rectal temperature measurement is contraindicated in neutropenic clients due to the risk of mucosal injury and bacterial translocation, which can lead to bloodstream infections (bacteremia). Instead, the client’s temperature should be monitored using an oral or tympanic thermometer to detect early signs of infection.

A. The best way to determine prostate cancer risk is to have a computed tomography (CT) scan. This statement is incorrect. A CT scan is not the primary method for prostate cancer screening. The most common screening tools include the prostatespecific antigen (PSA) blood test and digital rectal examination (DRE). If abnormalities are detected, further evaluation with a prostate biopsy or magnetic resonance imaging (MRI) may be warranted.
B. Prostate cancer mortality is more than double for Black American males than for men in every other group. This is the most accurate statement. Black American men have a significantly higher incidence of prostate cancer and are more than twice as likely to die from the disease compared to other racial or ethnic groups. Contributing factors include genetic predisposition, socioeconomic disparities, reduced access to early screening, and potential differences in tumor biology. Early screening and intervention are critical in this highrisk population.
C. Occupational toxin exposure among factory workers increases rates of prostate cancer by 30%. While some occupational exposures (e.g., pesticides, cadmium, and industrial chemicals) have been linked to a potential increased risk of prostate cancer, the exact percentage increase varies, and a direct causative link has not been definitively established. Other factors, such as genetic predisposition and lifestyle, play a more significant role.
D. Dietary factors can increase the risk of prostate cancer mortality by as much as 50%. While diet can influence prostate cancer risk, the claim that it increases mortality by 50% is not wellsupported by research. Diets high in red meat, saturated fats, and low in vegetables may contribute to increased risk, but the impact varies based on genetic and lifestyle factors. Antioxidantrich diets, such as those rich in fruits and vegetables, may have a protective effect.

A. Performing the procedure independently. This is the best indicator of readiness for discharge. The client’s partner must demonstrate the ability to perform tracheostomy suctioning correctly and safely without direct supervision. Proper technique includes using sterile equipment, maintaining appropriate suction pressure (80120 mmHg), limiting suction duration to 1015 seconds per pass, and allowing adequate oxygenation between passes to prevent hypoxia. Independent performance ensures the caregiver can manage airway clearance at home.
B. Verbalizing all steps in the procedure. While verbalizing the steps demonstrates understanding, it does not confirm the ability to perform suctioning correctly. Practical application is necessary to ensure competency in technique, infection control, and recognizing complications such as hypoxia or airway trauma.
C. Attending a class given about tracheostomy care. Education is essential, but attending a class alone does not confirm skill mastery. Handson practice and independent demonstration are required to ensure safe and effective tracheostomy management.
D. Asking appropriate questions about suctioning. Asking questions reflects engagement and willingness to learn, but it does not indicate that the caregiver can independently perform the procedure. Proper discharge readiness requires demonstrated competency through handson practice.

A. Add more water to the suction control chamber of the drainage system. While ensuring the water level in the suction control chamber is appropriate (usually around 20 cm H₂O for wet suction systems) is important, simply adding water without first verifying the suction setup and tubing integrity is not the initial action. Overfilling can lead to excessive negative pressure and potential tissue trauma.
B. Verify that the suction regulator is on and check the tubing for leaks. This is the most appropriate action. In a traditional wet suction system, continuous gentle bubbling should be present in the suction control chamber when suction is applied. If there is no bubbling, the nurse should first confirm that the suction regulator is turned on at the prescribed level and inspect the tubing for disconnections, kinks, or leaks that could be disrupting airflow.
C. Continue to monitor the client as this is an expected finding. No bubbling in a wet suction system is not an expected finding. It suggests an issue with suction application, such as incorrect settings or a problem with tubing connections. While intermittent bubbling in the water seal chamber may be normal, the suction control chamber should consistently bubble when connected to active suction.
D. Milk the chest tube and dislodge any clots in the tubing that are occluding it. Routine milking or stripping of a chest tube is generally not recommended unless specifically ordered by a healthcare provider, as it can create excessive negative pressure and damage lung tissue. If there is concern about occlusion, the nurse should assess for signs of impaired drainage (e.g., sudden cessation of output, respiratory distress) and notify the provider for further intervention.

A. Hematuria. While hematuria (blood in the urine) can indicate potential complications such as radiationinduced cystitis or coagulopathy, it is not the most urgent concern in a client with brain cancer. It should be reported and monitored, but immediate intervention is typically not required unless accompanied by signs of hemorrhagic shock or renal dysfunction.
B. Chest pain and dyspnea. Chest pain and dyspnea could indicate serious conditions such as pulmonary embolism, pneumonia, or cardiotoxicity from cancer treatment. While these symptoms are concerning and require prompt evaluation, in the context of brain cancer, they are not the most immediate neurological emergency compared to seizures.
C. Seizures. This is the most critical symptom to report immediately. Clients with brain cancer are at high risk for seizures due to tumorrelated irritation of the cerebral cortex, increased intracranial pressure (ICP), or radiationinduced brain swelling. Seizures can lead to further neurological compromise, aspiration, or even status epilepticus, which is a lifethreatening emergency. Immediate intervention with seizure precautions, airway protection, and possible administration of anticonvulsants or corticosteroids is required.
D. Swelling of the extremities Swelling of the extremities may be due to lymphedema, deep vein thrombosis (DVT), or radiationinduced inflammation. While this symptom should be assessed, it does not pose an immediate lifethreatening risk compared to seizures in a client with brain cancer.