Nursing a Concept Based Approach to Learning Test Bank Free

Correct Answer: B

Rationale: Assessing postural blood pressures is important in determining if the client may be experiencing orthostatic hypotension, which could have contributed to the fall. Orthostatic hypotension is a sudden drop in blood pressure that can occur when a person stands up from a sitting or lying position. Older adults on antihypertensive medications are at increased risk for orthostatic hypotension. By monitoring postural blood pressures, the nurse can identify fluctuations in blood pressure that may put the client at risk for falls and implement appropriate interventions to prevent future falls. Monitoring serum sodium levels and creatinine levels are important for detecting electrolyte imbalances or kidney dysfunction but do not directly address the issue of orthostatic hypotension related to falls. Monitoring blood pressure every 2 hours may not provide valuable information on postural blood pressure changes that are associated with orthostatic hypotension.

Correct Answer: C

Rationale: After an embolus becomes trapped in the pulmonary microvasculature, dead space increases. Dead space refers to the portion of the lung that is ventilated but not perfused, resulting in reduced gas exchange. When a pulmonary embolus blocks blood flow within a pulmonary vessel, it leads to a mismatch between ventilation and perfusion in the affected lung region. This mismatch results in increased dead space, as ventilation continues in areas that are not effectively perfused. As dead space increases, the overall efficiency of gas exchange in the lung is impaired, potentially leading to hypoxemia.

Correct Answer: B

Rationale: The client with cardiomyopathy may experience decreased cardiac output, which is a common manifestation of this condition. Cardiomyopathy is a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body. Reduced cardiac output means that less blood is being pumped out by the heart with each beat, leading to symptoms such as fatigue, weakness, and the need to rest between activities. This is why the client is experiencing the need to rest between activities during the day.

Correct Answer: B

Rationale: When caring for a laboring client diagnosed with preeclampsia, it is important to be mindful of certain considerations to ensure the safety and well-being of both the mother and the baby. Placing the client in left lateral position when she feels the urge to push is crucial in cases of preeclampsia as it helps to optimize maternal and fetal oxygenation. This position can help improve blood flow to the placenta and reduce the risk of decreased perfusion due to the elevated blood pressure associated with preeclampsia. By maintaining the client in the left lateral position during pushing, it can help prevent potential complications and support better outcomes for both the mother and baby.

Correct Answer: C

Rationale: The highest priority when caring for a patient with manifestations of appendicitis is to provide pain relief. By inserting a saline lock for intravenous pain medication, the patient can receive immediate pain relief to alleviate their discomfort. Pain management is crucial in appendicitis as it can help in improving the patient's overall well-being and reduce the risk of complications. While other options such as withholding food and fluids, performing preoperative skin preparation, or teaching postoperative exercises are important aspects of care, addressing the patient's pain is the top priority to ensure their comfort and well-being.