Concepts and Cases in Nursing Ethics Test Bank

Correct Answer: C

Rationale: A urine output of 200 mL in 8 hours is considered low, especially for a client with cardiomyopathy who is receiving diuretic therapy. This could indicate inadequate cardiac output or worsening heart failure. It is crucial for the nurse to notify the healthcare provider promptly so that appropriate interventions can be initiated to address the underlying cause and prevent further complications. Waiting for improvement without taking action could lead to deterioration in the client's condition.

Correct Answer: B

Rationale: Endocarditis is a common complication that individuals with repaired congenital heart defects may still be at risk for. Endocarditis is an infection of the inner lining of the heart chambers and valves. The altered structure of the heart tissue from the previous defect and surgery can create an increased risk for bacterial growth and infection. Patients with a history of congenital heart defects should be monitored for signs and symptoms of endocarditis, such as fever, fatigue, new heart murmurs, and evidence of systemic embolization. Prophylactic antibiotics before certain dental and surgical procedures may be recommended to prevent endocarditis in this population. Therefore, the nurse should be vigilant in monitoring for any symptoms suggestive of endocarditis in this client.

Correct Answer: C

Rationale: Ensuring that the nasogastric tube is functioning is the most important nursing action when caring for a patient with a paralytic ileus. A paralytic ileus is a condition where there is a temporary paralysis of the intestine, leading to a lack of bowel motility. This can result in a buildup of gas and fluids in the intestines, causing abdominal distension, pain, and potential complications.

Correct Answer: A

Rationale: A. Initiate oxygen therapy: Providing oxygen therapy is appropriate to ensure adequate oxygenation and tissue perfusion during episodes of paroxysmal supraventricular tachycardia.

Correct Answer: D

Rationale: Crepitation refers to a grating sound or sensation that occurs when there is rubbing together of the roughened articular surfaces of bones within a joint. It is commonly associated with conditions such as osteoarthritis or joint injury. Therefore, if the nurse hears a grating sound while assessing the range of motion of a patient's hip, the appropriate documentation of this finding would be crepitation.