A. The client has pneumonia in the bases: Crackles in the lung bases can suggest pneumonia; however, this finding alone does not confirm a diagnosis. Diagnosis requires clinical correlation with imaging findings such as consolidation or opacities and possibly labs. The physical deformity of the chest (sternal depression) is unrelated to the presence of pneumonia.
B. The client has chronic respiratory disease: While dyspnea and crackles may be seen in chronic respiratory diseases like COPD, the inspection finding of a depressed sternum is not characteristic of these conditions. An illness occurring for two days is also acute and cannot be termed chronic. Documenting a structural deformity based on inspection is more accurate than assuming a chronic disease.
C. The client has a funnel chest: Funnel chest, or pectus excavatum, is a deformity marked by a sunken appearance of the sternum, often more noticeable on inspiration. This is an accurate inspection-based finding that the nurse should document, separate from the respiratory symptoms.
D. The client needs a cough suppressant: A cough suppressant is a potential treatment option for symptomatic relief, but this does not relate to the inspection finding. The nurse’s role at this point is assessment and documentation, not treatment decisions based solely on visual inspection.

A. Dextromethorphan: Dextromethorphan is an antitussive commonly used to suppress non-productive coughs. It acts on the cough center in the medulla to reduce the frequency and intensity of coughing, making it ideal for nighttime relief.
B. Pseudoephedrine: Pseudoephedrine is a decongestant that reduces nasal congestion by vasoconstriction. It does not suppress cough and can actually cause insomnia due to its stimulant effects, making it inappropriate for nighttime use.
C. Diphenhydramine: Diphenhydramine is an antihistamine that may have mild cough suppressant properties and cause sedation. Its primary action is to block histamine receptors, which is more useful for allergic reactions and related symptoms like runny nose or itching. It's not a direct cough suppressant.
D. Fluticasone: Fluticasone is a corticosteroid typically used as a nasal spray for allergic rhinitis. It is not effective for acute cough relief and has no role in suppressing a dry, nighttime cough.

A. Inform the client that the position must be changed, and then you will give her pain medication and omit the bath: Changing the client’s position before providing pain relief can exacerbate discomfort and anxiety. Pain should be managed prior to any interventions that may cause further distress.
B. Inform the client that she will feel better after receiving a bath and clean sheets: While hygiene and comfort are important, suggesting a bath will make the client feel better without addressing their pain first minimizes the severity of their symptoms and lacks therapeutic empathy.
C. Inform the client that the bath and positioning is an important part of client care and will be done right after pain medication administration: Although this acknowledges the need for pain control, it still implies the procedures will begin immediately after medication administration, not allowing time for the analgesic to take effect.
D. Obtain the pain medication and delay the bath and position change until the medication reaches its peak: This is the most appropriate action. Administering pain medication first and allowing it to reach peak effectiveness ensures the client experiences less pain during movement and hygiene care, which demonstrates a compassionate, patient-centered approach.

A. Maintain activity restriction to bedrest: Bedrest reduces the heart's workload by minimizing physical exertion, thereby decreasing myocardial oxygen demand. This is crucial in cardiogenic shock, where the heart's pumping ability is severely compromised.
B. Limit interaction with visitors: While excessive stimulation can be stressful, limiting social interaction has a minimal impact on myocardial oxygen consumption compared to physical activity. Emotional support from visitors can actually benefit the client’s overall well-being.
C. Avoid heavy meals: Heavy meals may cause postprandial increases in metabolic demand, but they are not as directly impactful on cardiac workload as restricting physical activity. Meal composition should still be considered, but it's not the most immediate priority.
D. Arrange personal care supplies nearby: Placing supplies within reach helps minimize exertion during ADLs, but this is a supportive measure. Complete activity restriction is a more direct and effective intervention to reduce cardiac oxygen demand in the acute phase.

A. Basilic vein: The basilic vein is located in the arm and is not typically used for coronary artery bypass grafting. It is more commonly used for vascular access, such as in arteriovenous fistulas for dialysis.
B. Gastroepiploic artery: The gastroepiploic artery can be used in coronary bypass surgery but is less commonly selected due to its location in the abdomen and the technical challenges associated with harvesting it.
C. Radial artery: The radial artery is sometimes used as a graft, especially when multiple grafts are needed, but it is not the most commonly used vessel. It is often chosen for its muscular wall and long-term patency.
D. Saphenous vein: The saphenous vein, located in the leg, is the most commonly used vessel for coronary artery bypass grafting due to its length, ease of access, and suitability for multiple grafts. It has been a standard choice for decades.

A. The client will have to take higher doses of the antiviral medications: Increasing the dose is not a standard or safe response to missed doses. Higher doses do not compensate for inconsistent use and may increase the risk of toxicity without improving outcomes.
B. The client will have to take the drugs intravenously to ensure compliance: Intravenous administration is not used as a compliance strategy for antiretrovirals. Most antiretroviral drugs are formulated for oral use, and adherence is managed through education and support, not route changes.
C. The client is risking the development of drug resistance and drug failure: Missing doses of antiretroviral therapy allows the virus to replicate, which increases the risk of developing mutations. This can lead to drug resistance, making the current regimen ineffective and limiting future treatment options.
D. The funding for the medications will cease if the client is not taking the meds correctly: Access to medication is not typically revoked due to non-adherence. While adherence is essential, patients are encouraged to be honest so that healthcare providers can support them rather than penalize them.

A. The client should have a bowel movement every day to avoid development of an intestinal obstruction: While regular bowel movements are important, going two days without one is not uncommon and does not usually lead to obstruction. The priority in heart failure is avoiding strain, not frequency alone.
B. The client can develop a rectal fissure, which will increase pain levels: Although rectal fissures can occur with hard stools, they are not the primary concern in a heart failure patient. The hemodynamic effects of straining pose a greater immediate risk.
C. The client should not develop hemorrhoids: Preventing hemorrhoids is beneficial but not critical in the context of heart failure. The concern with straining extends beyond local complications like hemorrhoids to systemic cardiovascular effects.
D. Straining engages the Valsalva maneuver, which can cause dangerous effects: The Valsalva maneuver increases intrathoracic pressure, reducing venous return and cardiac output. In clients with heart failure, this can trigger arrhythmias, syncope, or even cardiac decompensation, making stool softeners essential for prevention.

A. Fever, sore throat, and chills: These are classic signs of infection and are especially concerning in leukopenia, where the body’s ability to fight infections is compromised due to a low white blood cell count. Prompt recognition is critical for early intervention.
B. Nausea and vomiting: While these may be side effects of many medications, they are not specific indicators of leukopenia. They reflect gastrointestinal irritation rather than immunosuppression.
C. Intolerance to heat and rash: These symptoms are more consistent with thyroid dysfunction or allergic reactions, not leukopenia. They do not suggest a compromised immune response.
D. Diarrhea, diaphoresis, and fever: Though fever can be a sign of leukopenia-related infection, diarrhea and diaphoresis are nonspecific symptoms and may relate to other systems or drug side effects. Fever, sore throat, and chills are more indicative of infection due to leukopenia.

A. Administer benzodiazepine as ordered: Benzodiazepines are the first-line treatment for alcohol withdrawal because they reduce central nervous system hyperexcitability, preventing seizures and delirium tremens. The client's elevated vital signs indicate severe withdrawal, requiring immediate pharmacologic intervention.
B. Provide emotional support: Emotional support is important, but in acute alcohol withdrawal with signs of autonomic hyperactivity, stabilizing the patient medically takes precedence over psychosocial interventions.
C. Encourage the client to rest: While rest may help reduce stimulation, it is not sufficient to control severe withdrawal symptoms. The client needs medication to prevent progression to life-threatening complications.
D. Monitor for any further changes: Ongoing monitoring is necessary, but immediate action is required first. Waiting without intervention in the face of escalating symptoms can lead to worsening instability, including seizures or hypertensive crisis.

A. "I will drink at least 3 L of fluid per day.": While staying hydrated is beneficial, fluid intake is not directly related to the side effects or safety concerns of azathioprine. Some medications can affect the kidneys, making hydration crucial, but it's not the primary concern related to immune suppression.
B. "I will stop taking my medication if I notice any side effects and then notify the doctor.": Abruptly discontinuing azathioprine without physician approval may worsen Crohn's disease or cause withdrawal issues. Medication changes should always be guided by the healthcare provider to ensure safety and continuity of care.
C. "I will notify the doctor if I am not having a bowel movement daily.": Constipation is not a primary concern with azathioprine therapy, and bowel patterns may vary with Crohn’s flares. Monitoring for signs of infection or bone marrow suppression is far more critical with this drug.
D. "I will notify the doctor if I have a fever or any other signs of infection.":
Azathioprine suppresses immune function, increasing the risk for potentially serious infections. Prompt reporting of fever allows for early intervention to prevent sepsis or other complications in immunocompromised individuals.