B. Tidaling is an expected finding in a functioning chest drainage system and indicates proper drainage of air or fluid from the pleural space. Continuously monitoring the drainage system allows the nurse to assess the volume, color, and consistency of drainage.
A. Rising water levels during inspiration and falling during expiration are indicative of proper chest tube function, therefore, auscultation for breath sounds may not provide additional relevant information related to the functioning of the chest tube.
C. Performing this action unnecessarily may disrupt the functioning of the drainage system and should only be done if specifically instructed by the healthcare provider.
D. While it is important to monitor for leaks, the observation of tidaling in the water-seal chamber does not necessarily indicate a leak at the insertion site.

A. One of the most common triggers is a distended bladder. When the bladder becomes full, it sends signals to the spinal cord, but due to the injury, these signals are unable to pass beyond the level of injury. This results in uncontrolled sympathetic activation, leading to symptoms such as hypertension, sweating, and headache.
B. Forehead diaphoresis, or sweating, is a potential symptom of autonomic dysreflexia. However, it is more of a consequence rather than a precipitating factor. It occurs as a result of sympathetic nervous system activation in response to the triggering stimulus.
C. Skeletal traction misalignment is not a common precipitating factor for autonomic dysreflexia. Autonomic dysreflexia is typically triggered by stimuli related to visceral or autonomic reflexes, such as bladder distention or bowel impaction, rather than mechanical issues like traction misalignment.
D. A severe pounding headache can occur as a symptom of autonomic dysreflexia, but it is not the primary precipitating factor. The headache is a result of the sudden increase in blood pressure that occurs during autonomic dysreflexia.

To determine the mL/hr rate for the regular insulin infusion, we can set up a proportion: 10 units/hr (prescribed rate) = x mL/hr (unknown rate)

Since the IV solution contains 100 units of regular insulin in 100 mL of 0.9% normal saline, we know that each mL of the solution contains 1 unit of regular insulin.

So, if 1 mL contains 1 unit, then x mL contains 10 units. x = 10 mL/hr

A. This choice involves culturing a sputum sample collected from the patient to identify the presence of Mycobacterium tuberculosis, the bacterium that causes tuberculosis. A positive result confirms the diagnosis of TB.
B. Hemoccult tests are used to detect hidden (occult) blood in stool samples. While hemoptysis (coughing up blood) can be a symptom of TB, a hemoccult test is not specific for TB diagnosis. It is more commonly used in detecting gastrointestinal bleeding.
C. Imaging studies like chest x-ray or CT scans can reveal abnormalities in the lungs suggestive of TB, such as infiltrates, cavitations, or lymph node enlargement. While these tests can support the diagnosis, they are not definitive on their own.
D. The PPD skin test is a common screening tool for TB exposure. It detects the presence of a delayed hypersensitivity reaction to proteins derived from Mycobacterium tuberculosis. A positive PPD indicates exposure to TB but does not confirm active disease.

B. Lactulose works by acidifying the colonic contents, which promotes the conversion of ammonia (NH3) to ammonium (NH4+). Ammonium is less readily absorbed from the colon into the bloodstream, reducing systemic ammonia levels. This action helps alleviate the neurotoxic effects of ammonia on the brain, thereby improving neurological symptoms associated with hepatic encephalopathy.
A. Lactulose is required in clients with hepatic encephalopathy to excrete ammonia lowering its levels in blood. Holding the lactulose dose is inappropriate as the client’s ammonia levels are still high
C. Rehydrating the clients to replace lost fluids in the loose stools is important but does not address
the client’s elevated ammonia levels which may be exacerbating the client’s encephalopathy.
D. Reporting the number of diarrhea stools to the healthcare provider is important for ongoing assessment and management of the client's condition. However, it does not address the clients high ammonia levels.

C. Peptic ulcer disease involves the formation of open sores in the lining of the stomach or the duodenum. The characteristic symptom of PUD is abdominal pain, typically located in the upper mid abdomen. This pain is often described as gnawing, burning, or aching in nature. The pain may occur shortly after eating, especially when the stomach is empty (gastric ulcer), or it may occur 2-3 hours after eating, typically at night (duodenal ulcer).
A. describes symptoms more suggestive of irritable bowel syndrome (IBS) or gastrointestinal sensitivity to spicy foods, leading to cramps and diarrhea, but it is less specific to PUD.
B. indicates frequent use of antacids for indigestion, which may suggest symptoms of acid reflux or gastritis but do not specifically point to the presence of peptic ulcers.
D. suggests more severe systemic issues such as malignancy or chronic diseases rather than solely PUD.

A. Complete restriction of physical activities is not necessary. The nurse should provide guidance on gradually resuming normal activities based on the healthcare provider's recommendations.

B. Incentive spirometer is not directly related to the management or recovery following TUNA for BPH. This device is typically used to improve lung function and prevent respiratory complications, which may not be a primary concern in this scenario.

C.While clients should monitor hematuria, the primary focus post-TUNA is on urinary output and function rather than just the color of the urine. Changes in hematuria color are important, but they may not directly correlate to urgent issues.
D. After TUNA, clients need to be vigilant about their urinary output because a decrease can indicate complications such as re-obstruction, which is a significant concern following the procedure. Monitoring urinary stream is essential for detecting potential issues early, making this the best choice for discharge instructions.

A. Clients receiving thrombolytic therapy are at an increased risk of bleeding, which can manifest as internal bleeding, hemorrhage at vascular access sites, gastrointestinal bleeding, or intracranial bleeding. The nurse's priority is to closely monitor the client for signs and symptoms of bleeding, such as sudden onset or worsening of headache, changes in level of consciousness, hematuria, melena, ecchymosis, or hematoma formation.
B. While activity intolerance is a common nursing diagnosis for clients following an acute myocardial infarction due to myocardial ischemia, it is not the priority in this case where the client is actively receiving thrombolytic therapy.
C. While respiratory complications can occur following thrombolytic therapy, such as pulmonary embolism or bleeding into the lungs, the risk of bleeding complications takes precedence as the priority nursing problem for this client.
D. Education about the new medication regimen is important for client understanding and adherence, but it is not the priority nursing problem in the immediate post-thrombolytic therapy period.

A. A high-pitched sound heard upon inspiration, known as a "stridor," can indicate airway obstruction or respiratory distress. In the postoperative period following an appendectomy, airway patency and adequate ventilation are essential for the client's oxygenation and recovery.
B. While a slightly elevated heart rate may be expected in the immediate postoperative period due to stress or pain, it does not typically require immediate action unless accompanied by other concerning symptoms.
C. Redness and edema at the incision site can be normal inflammatory responses following surgery.
D. Pain is common after surgery, and a pain rating of 8 on a scale of 0 to 10 indicates moderate to severe pain.

Left ventricular dysfunction leads to inadequate stroke volume and cardiac output to the systemic circulation. This leads to fatigue and exertional dyspnea.
B. Lower extremity is a typical finding in right ventricular dysfunction. Inadequate pumping in the right ventricular leads to volume overload in the systemic circulation.
C. Hepatomegaly is a typical finding in right ventricular dysfunction
D. Jugular vein dysfunction is a typical finding in right ventricular dysfunction.