Choice A rationale

Jugular vein distention suggests fluid overload or congestive heart failure due to increased central venous pressure. This finding is unrelated to allergic reactions and does not indicate the need for diphenhydramine, which is an antihistamine used for allergic symptoms. Monitoring fluid balance and addressing the underlying cause of fluid overload are appropriate interventions for such cases.

Choice B rationale

Pulmonary congestion indicates fluid accumulation in the lungs, often due to left-sided heart failure or volume overload. This is not associated with allergic reactions. Diphenhydramine would not be appropriate for managing this finding as it is not effective for conditions requiring diuresis or cardiac support. Pulmonary congestion requires treatment targeting the underlying etiology, such as diuretics or afterload reduction.

Choice C rationale

Urticaria, also known as hives, is a classic symptom of an allergic reaction. It occurs due to histamine release from mast cells and basophils, leading to localized vasodilation and increased vascular permeability. Diphenhydramine is effective in managing urticaria by antagonizing histamine H1 receptors, thereby reducing itching and swelling caused by the allergic reaction.

Choice D rationale

Hypotension during a transfusion can indicate a severe transfusion reaction, such as anaphylaxis or hemolysis. While diphenhydramine might help alleviate mild allergic symptoms, hypotension requires urgent hemodynamic support and further evaluation to determine its cause. Management may include intravenous fluids, vasopressors, and stopping the transfusion.

Step 1 is (150 lb × 1 kg ÷ 2.2 lb) × 250 units. This calculates the total units required. The answer is 17045.45 units.

Step 2 is 17045.45 units ÷ 10,000 units/mL = 1.7 mL.

The final calculated answer is 1.7 mL.

Choice A rationale

Rating pain on a scale from 0 to 10 assesses pain intensity rather than quality. Intensity quantifies the severity of pain but does not describe its characteristics, such as sharpness, dullness, or burning, which are essential for understanding the pain's nature and underlying etiology.

Choice B rationale

Asking about pain presence or absence identifies whether the client is experiencing pain but provides no information about its quality. This question is insufficient for determining pain characteristics, which require descriptive responses to guide appropriate intervention and diagnosis.

Choice C rationale

Asking the client what their pain feels like elicits a description of pain quality. Quality includes terms such as throbbing, sharp, or burning, which help identify the type of pain and its potential causes, differentiating between nociceptive, neuropathic, or referred pain.

Choice D rationale

Comparing current pain to previous pain assesses pain trends and patterns but does not address the quality of the pain. This question is more suited for evaluating treatment effectiveness over time rather than diagnosing the nature of the pain.

Choice A rationale

Current medication prescriptions provide critical information about the client's ongoing treatments, including dosages, routes, and frequencies. This ensures continuity of care and prevents medication errors during the transition to the intensive care unit, promoting patient safety.

Choice B rationale

The primary health problem outlines the client's current medical condition necessitating transfer. It informs the receiving team about the clinical priorities and guides immediate care and management decisions to address the client’s needs effectively.

Choice C rationale

Scheduled times for dressing changes offer minimal relevance in an emergency transfer situation. While it provides routine care information, it does not impact immediate critical care and thus is less vital than other elements of the report.

Choice D rationale

The number of family members visiting holds no significance for transfer documentation. This detail does not affect medical care or provide essential information to the receiving unit and therefore is excluded from critical documentation.

Choice E rationale

Admission vital signs from a week ago are outdated and do not reflect the client’s current physiological status. Providing recent or trending vital signs is crucial to conveying the severity of the client's condition and enabling prompt intervention.

Choice A rationale

Acyclovir reduces the frequency and severity of herpes outbreaks but does not prevent transmission. The virus can still be spread through asymptomatic viral shedding, and unprotected sex increases the risk of transmitting the infection to partners.

Choice B rationale

Herpes simplex virus type 2 primarily affects the genital area but can spread to other locations, such as the mouth or fingers, through direct contact with infected secretions. This statement is scientifically incorrect and reflects a lack of understanding.

Choice C rationale

Stress weakens the immune system, triggering latent herpes simplex virus reactivation. This leads to the recurrence of lesions as the virus travels along the nerve pathways to the skin or mucous membranes. Management includes antiviral medications and stress reduction strategies.

Choice D rationale

Herpes simplex virus is contagious even without visible lesions due to asymptomatic viral shedding. The virus can be transmitted to sexual partners during this period, making barrier protection essential at all times to reduce transmission risk. .

Choice A rationale

Current medication prescriptions are essential for ensuring continuity of care. Accurate documentation prevents medication errors and allows the receiving unit to administer the right medications at the correct times and dosages. It ensures the client’s therapeutic regimen continues uninterrupted and facilitates the management of conditions during the transfer process.

Choice B rationale

The primary health problem outlines the central issue requiring intensive care. This information is vital for prioritizing interventions and forming a focused care plan. It ensures the receiving team understands the client’s critical health needs and can provide the appropriate monitoring and treatment promptly.

Choice C rationale

Scheduled times for dressing changes are not typically included in transfer documentation because they represent non-urgent routine tasks. Prioritization is given to critical information like the client’s current condition and medical orders to ensure safety during the transition to the intensive care unit.

Choice D rationale

The number of family members who have visited is irrelevant to the clinical transfer process. Documentation should focus solely on medical and therapeutic information critical to the client’s ongoing care and safety, ensuring efficient communication between healthcare providers.

Choice E rationale

Admission vital signs from a week ago do not reflect the client’s current condition and are not useful for guiding care. Transfer documentation should include recent and relevant clinical data to assist the receiving team in assessing and managing the client’s immediate needs.

Choice A rationale

Numbness of the affected extremity is not a classic symptom of deep-vein thrombosis (DVT). DVT primarily affects venous circulation, causing symptoms like pain, swelling, and warmth, rather than sensory deficits like numbness, which are more indicative of nerve involvement or arterial issues.

Choice B rationale

Muscle spasms are not a hallmark sign of DVT. They are typically associated with muscular or neuromuscular issues. DVT symptoms are more focused on vascular changes such as pain, swelling, and increased warmth in the affected area due to impaired venous return.

Choice C rationale

Warmth of the affected extremity occurs due to localized inflammation caused by clot formation in the vein. The body’s inflammatory response to the thrombus leads to vasodilation and increased blood flow to the area, resulting in the sensation of warmth upon palpation.

Choice D rationale

An absent pedal pulse is not indicative of DVT, as this condition involves venous, not arterial, circulation. A missing pulse suggests arterial occlusion or peripheral vascular disease, distinct from venous thromboembolism like DVT.

Choice A rationale

Instructing the client to tilt their head back increases the risk of aspiration by misaligning the airway and esophagus. Clients with dysphagia require strategies that minimize the risk of aspiration and promote safe swallowing, such as a neutral head position or chin tuck.

Choice B rationale

Scheduling physical therapy directly before meals is inappropriate as it may cause fatigue, reducing the client’s ability to eat safely. Proper scheduling ensures clients have sufficient energy to focus on eating, essential for minimizing aspiration risks in those with dysphagia.

Choice C rationale

Providing oral care before meals reduces the bacterial load in the oral cavity, lowering the risk of aspiration pneumonia if food or liquids are accidentally aspirated. Maintaining good oral hygiene is a key preventive measure for complications related to dysphagia.

Choice D rationale

Encouraging the use of a straw is contraindicated as it can increase the risk of aspiration. Using a straw can direct liquids forcefully to the throat, overwhelming the client’s ability to control swallowing, which is a safety concern for individuals with dysphagia.

Choice A rationale

Cutting the skin barrier opening 1/4 inch larger than the stoma prevents pressure on the stoma while ensuring a secure fit. This size accommodates natural stoma expansion during peristalsis, minimizes leakage, and reduces irritation to the peristomal skin.

Choice B rationale

Emptying the pouch when it is 1/3 to 1/2 full is recommended to prevent excessive weight, which can cause the adhesive barrier to loosen. Regular emptying maintains hygiene, reduces odors, and ensures comfort for the client, enhancing ostomy care.

Choice C rationale

Cleansing the skin surrounding the stoma with moisturizing soap is inappropriate as it leaves a residue that can interfere with the adhesive barrier's seal. Instead, non-moisturizing, residue-free cleansers are recommended to optimize ostomy barrier adhesion.

Choice D rationale

Using a standard enema set to irrigate the colostomy is not standard practice. Colostomy irrigation requires specialized equipment and careful technique to prevent mucosal trauma. Routine irrigation is typically advised for clients with specific medical conditions or stoma types.

Choice A rationale

Oatmeal is not rich in vitamin C, which is needed to enhance the absorption of ferrous sulfate. While it provides fiber, its role in iron therapy is limited compared to vitamin C-rich options, which significantly improve iron solubility and uptake.

Choice B rationale

Raw oranges are an excellent source of vitamin C, which significantly enhances the absorption of non-heme iron like ferrous sulfate. Vitamin C reduces ferric iron to ferrous iron, promoting absorption in the duodenum, a critical factor in anemia management.

Choice C rationale

Baked potatoes contain minimal vitamin C compared to other food options like citrus fruits. While they have nutritional benefits, they do not significantly enhance iron absorption, making them less effective for optimizing ferrous sulfate therapy.

Choice D rationale

Cheese is calcium-rich, and calcium competes with iron for absorption in the gastrointestinal tract. Consuming calcium alongside ferrous sulfate can decrease its bioavailability, making cheese an unsuitable choice for improving iron absorption. .