Choice A reason: Sitting upright improves breathing but doesn’t address the critical hypoxia indicated by 85% pulse oximetry. Applying oxygen directly corrects low oxygen levels, making this secondary and incorrect compared to the nurse’s priority of ensuring adequate oxygenation in a heart failure exacerbation.

Choice B reason: Calling for intubation anticipates worsening but is premature without first addressing hypoxia with oxygen. Applying oxygen is the immediate need, making this incorrect, as it bypasses the initial step of improving oxygenation in the client with severe respiratory distress.

Choice C reason: Preparing for a Foley catheter anticipates diuresis but doesn’t address the urgent hypoxia at 85% oxygen saturation. Applying oxygen is critical, making this incorrect, as it delays the primary intervention needed to stabilize the client’s respiratory status in heart failure.

Choice D reason: Applying oxygen is the first action to correct hypoxia (pulse oximetry 85%), improving tissue oxygenation in heart failure exacerbation. This aligns with acute care priorities, making it the correct intervention to address the client’s immediate respiratory distress and low oxygen saturation effectively.

Choice A reason: Cough suppressants may reduce discomfort but don’t address hypoxia risk during thoracentesis in COPD exacerbation. Oxygen application ensures safety, making this incorrect, as it doesn’t prioritize respiratory support needed for the client undergoing a procedure affecting lung function.

Choice B reason: A prone position is unsafe for thoracentesis, which requires an upright or side-lying position to access pleural fluid. Oxygen supports breathing, making this incorrect, as it risks procedural complications compared to ensuring oxygenation for the COPD client’s safety.

Choice C reason: Arterial blood gases post-procedure assess respiratory status but aren’t the primary safety intervention during thoracentesis. Oxygen prevents hypoxia, making this secondary and incorrect compared to the immediate need for respiratory support in the COPD client undergoing the procedure.

Choice D reason: Applying oxygen via nasal cannula ensures adequate oxygenation during thoracentesis, critical for a COPD client with exacerbation prone to hypoxia. This aligns with procedural safety protocols, making it the correct intervention to maintain client safety during the pleural fluid removal.

Choice A reason: Rolling down tight stockings creates a tourniquet effect, worsening venous insufficiency. Elevating feet improves circulation, making this incorrect, as it reflects a misunderstanding of compression therapy compared to the correct management taught by the nurse for venous insufficiency.

Choice B reason: Putting on stockings after swelling begins is less effective than wearing them preventatively. Elevating feet reduces edema, making this incorrect, as it shows partial understanding compared to the proactive elevation strategy indicating full comprehension of the nurse’s teaching.

Choice C reason: Elevating feet when sitting promotes venous return, reducing edema in venous insufficiency. This aligns with self-care education for the condition, making it the correct statement, as it demonstrates the client’s accurate understanding of the nurse’s teaching to manage lower extremity swelling.

Choice D reason: Crossing legs impairs venous return, exacerbating venous insufficiency, regardless of duration. Elevating feet is correct, making this incorrect, as it reflects a misconception about safe practices compared to the nurse’s teaching on managing venous insufficiency effectively.

Choice A reason: Decreased cardiac output is a hallmark of cardiogenic shock, as the heart fails to pump adequately. This aligns with shock pathophysiology, making it a correct manifestation the nurse would expect when assessing a client for cardiogenic shock in a clinical setting.

Choice B reason: Increased pulse rate occurs in cardiogenic shock as the body compensates for low cardiac output. This aligns with cardiovascular assessment findings, making it a correct manifestation the nurse would identify in a client experiencing cardiogenic shock during evaluation.

Choice C reason: Postural hypotension is more typical of hypovolemic or orthostatic issues, not cardiogenic shock, which features weak pulses. Weak thready pulse is correct, making this incorrect, as it’s not a primary sign of cardiogenic shock in the nurse’s assessment.

Choice D reason: Bounding pulse suggests hyperdynamic circulation, not cardiogenic shock, where perfusion is poor. Weak thready pulse is typical, making this incorrect, as it does not reflect the compromised cardiac output expected in the nurse’s evaluation of cardiogenic shock.

Choice E reason: Weak thready pulse indicates poor perfusion in cardiogenic shock due to reduced cardiac output. This aligns with peripheral vascular assessment, making it a correct manifestation the nurse would expect when assessing a client in cardiogenic shock.

Choice F reason: Hypertension is not typical in cardiogenic shock, which often presents with hypotension due to pump failure. Pink frothy sputum is correct, making this incorrect, as it contradicts the hemodynamic profile in the nurse’s assessment of cardiogenic shock.

Choice G reason: Capillary refill greater than 3 seconds reflects poor perfusion in cardiogenic shock, consistent with low cardiac output. This aligns with peripheral assessment findings, making it a correct manifestation the nurse would note in a client with cardiogenic shock.

Choice H reason: Capillary refill less than 3 seconds suggests normal perfusion, not cardiogenic shock, where refill is delayed. Greater than 3 seconds is correct, making this incorrect, as it does not align with the poor perfusion in cardiogenic shock assessment.

Choice I reason: Pink frothy sputum indicates pulmonary edema, common in cardiogenic shock due to left heart failure. This aligns with respiratory assessment findings, making it a correct manifestation the nurse would expect in a client with cardiogenic shock.

Choice A reason: Nausea and vomiting may occur with nitroglycerin, but depression, fatigue, and impotence are unrelated. Headache and hypotension are primary effects, making this incorrect, as it includes irrelevant symptoms compared to the nurse’s teaching on nitroglycerin’s expected side effects.

Choice B reason: Sedation, constipation, and respiratory depression are opioid effects, not nitroglycerin, which causes vasodilation. Dizziness and flushing are correct, making this incorrect, as it misattributes opioid side effects to nitroglycerin in the nurse’s education for angina management.

Choice C reason: Nitroglycerin causes headache, hypotension, dizziness, and flushing due to vasodilation, common side effects. This aligns with pharmacological education for angina, making it the correct set of symptoms the nurse would teach the client to expect after taking sublingual nitroglycerin.

Choice D reason: Pedal edema is not a nitroglycerin side effect, though flushing, dizziness, and headache are. Hypotension is more precise than edema, making this incorrect, as it includes an unrelated symptom compared to the accurate side effects in nitroglycerin teaching.

Choice E reason: Decreased cardiac output and peripheral edema are not nitroglycerin effects; it improves coronary flow. Flushing is correct, but hypotension is key, making this incorrect, as it misrepresents nitroglycerin’s pharmacological effects in the nurse’s teaching for angina relief.

Choice A reason: Seizure precautions are relevant but secondary to establishing IV access for antihypertensive administration in hypertensive crisis. Starting an IV enables immediate treatment, making this incorrect, as it delays the critical intervention needed to lower the client’s dangerously high blood pressure.

Choice B reason: Instructing to report vision changes monitors complications but doesn’t address the urgent need to lower blood pressure. IV access facilitates medication delivery, making this incorrect, as it postpones the primary action for managing the client’s hypertensive crisis effectively.

Choice C reason: Elevating the bed may reduce intracranial pressure but is less urgent than starting an IV for antihypertensive drugs. IV access is the priority, making this incorrect, as it delays the critical intervention to manage the client’s severe hypertension in the emergency department.

Choice D reason: Starting a peripheral IV is the first action to enable rapid administration of antihypertensive medications in hypertensive crisis. This aligns with emergency care protocols for blood pressure 254/139 mm Hg, making it the correct initial step to stabilize the client’s condition.

Choice A reason: Nonmaleficence ensures no harm but is less central than veracity, which ensures truthful disclosure for informed consent. Truthfulness enables autonomous decisions, making this incorrect, as it’s secondary to the ethical priority of honesty in the consent process for femur surgery.

Choice B reason: Fidelity involves keeping promises but doesn’t directly address the truthful disclosure required for informed consent. Veracity ensures the patient understands risks, making this incorrect, as it’s less relevant than honesty in the nurse’s role during the consent process for surgery.

Choice C reason: Beneficence promotes well-being but is secondary to veracity, which provides accurate information for the patient’s decision. Truthfulness is critical for consent, making this incorrect, as it’s not the primary ethical principle when soliciting informed consent for the femur procedure.

Choice D reason: Veracity, or truthfulness, is the most important ethical principle, ensuring the patient receives accurate information about risks and benefits for informed consent. This aligns with surgical ethical standards, making it the correct principle for the nurse to prioritize during the consent process.

Choice A reason: Shortness of breath is a heart failure symptom, not a furosemide side effect, which causes diuresis. Lightheadedness from hypotension is common, making this incorrect, as it confuses disease symptoms with medication effects in the nurse’s monitoring plan for furosemide.

Choice B reason: Lightheadedness is a common furosemide adverse effect due to hypotension or electrolyte imbalances from diuresis. This aligns with pharmacological monitoring for heart failure treatment, making it the correct effect the nurse should plan to monitor in the client.

Choice C reason: Dry cough is associated with ACE inhibitors, not furosemide, a diuretic causing hypotension. Lightheadedness is a furosemide effect, making this incorrect, as it misattributes a side effect to the wrong medication in the nurse’s monitoring for heart failure treatment.

Choice D reason: Bitter taste is not a typical furosemide side effect; it’s more linked to medications like antibiotics. Lightheadedness is relevant, making this incorrect, as it does not reflect the expected adverse effects the nurse should monitor with furosemide administration.

Choice A reason: Analyzing care levels is important, but the nurse’s negligence lies in not addressing the critical magnesium level. Reporting to the practitioner is the appropriate action, making this incorrect, as it’s less specific than the failure to act on a critical lab result.

Choice B reason: Respecting patient wishes relates to DNR but doesn’t negate the need to report critical labs for non-resuscitative care. Failure to act is the issue, making this incorrect, as it misapplies the DNR to the nurse’s duty to address the magnesium level.

Choice C reason: Wrongful death assumes patient harm or death, which isn’t indicated here. Failure to act on the critical magnesium level is the negligence, making this incorrect, as it overstates the outcome compared to the nurse’s inaction on the lab result.

Choice D reason: Failure to take appropriate action, such as reporting a critical magnesium level of 1.1 mEq/L, is negligent, regardless of DNR status. This aligns with nursing standards, making it the correct action the nurse neglected, as critical labs require practitioner notification.

Choice A reason: Sodium of 130 mEq/L indicates hyponatremia, likely from vomiting-induced sodium loss. This aligns with the child’s electrolyte profile and symptoms, making it a correct imbalance the nurse would identify as most likely based on the lab values and clinical presentation.

Choice B reason: Calcium of 9.5 mg/dL is normal, not indicating hypocalcemia. Hyponatremia and metabolic alkalosis match the labs (sodium 130, HCO3 30), making this incorrect, as it does not reflect the child’s electrolyte imbalances from vomiting and irregular pulse.

Choice C reason: Potassium of 3.3 mEq/L is low, not high, ruling out hyperkalemia. Hyponatremia and metabolic alkalosis fit the labs and vomiting history, making this incorrect, as it contradicts the child’s potassium level in the nurse’s assessment of imbalances.

Choice D reason: Potassium of 3.3 mEq/L suggests mild hypokalemia, but hyponatremia (sodium 130) is more prominent with vomiting. Metabolic alkalosis is also evident, making this partially correct but incorrect as the primary imbalance compared to hyponatremia in the child’s profile.

Choice E reason: HCO3 of 30 mEq/L indicates alkalosis, not acidosis, due to vomiting-induced hydrogen ion loss. Hyponatremia and metabolic alkalosis are correct, making this incorrect, as it contradicts the child’s alkalotic state in the nurse’s evaluation of lab values.

Choice F reason: HCO3 of 30 mEq/L indicates metabolic alkalosis, common with vomiting due to loss of acidic gastric contents. This, with hyponatremia, aligns with the child’s labs and symptoms, making it a correct imbalance the nurse would identify in the assessment.