When assessing a client, the nurse should establish which finding(s) as objective? (Select all that apply.).
Urticaria.
Hypertension.
Diaphoresis.
Nausea.
Anxiety.
Edema.
Correct Answer : A,C,F
Choice A rationale:
Urticaria is a skin condition characterized by the sudden appearance of raised, itchy, and red welts on the skin. It is an objective finding because it can be observed and assessed visually. The presence of urticaria may indicate an allergic reaction or another underlying condition.
Choice B rationale:
Hypertension is a subjective finding because it cannot be directly observed. It requires blood pressure measurement to confirm, making it a subjective parameter.
Choice C rationale:
Diaphoresis refers to excessive sweating, which can be observed and assessed visually. It is an objective finding and may be indicative of various conditions, including anxiety or fever.
Choice D rationale:
Nausea is a subjective symptom because it is a sensation that the client experiences and reports. It cannot be directly observed by the nurse, making it a subjective parameter.
Choice E rationale:
Anxiety is a subjective symptom, as it is a mental and emotional state experienced by the client. It cannot be directly observed, making it a subjective parameter.
Choice F rationale:
Edema is an objective finding because it can be visually assessed by the nurse. Edema is the accumulation of excess fluid in body tissues, and its presence or absence can be objectively determined.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
Choice A rationale:
A pH level of 7.35 to 7.45 and HCO3- level of 22 to 26 mEq/L indicate a resolution of ketoacidosis. The normal pH range for the body is 7.35 to 7.45, and a return to this range indicates that the body’s acid-base balance has been restored. The bicarbonate (HCO3-) level is a measure of the metabolic component of the body’s acid-base balance, and the normal range is 22 to 26 mEq/L. A return to this range indicates that the metabolic acidosis caused by the ketoacidosis has been resolved.
Choice B rationale:
A pH level of 7.25 to 7.35 and HCO3- level of 18 to 22 mEq/L would indicate that the client is still in a state of mild acidosis, as the pH is below the normal range and the bicarbonate level is also slightly low, indicating a metabolic acidosis.
Choice C rationale:
A pH level of 7.15 to 7.25 and HCO3- level of 14 to 18 mEq/L would indicate a moderate acidosis. Both the pH and bicarbonate levels are significantly below their normal ranges, indicating a significant disruption in the body’s acid-base balance.
Choice D rationale:
A pH level of 7.05 to 7.15 and HCO3- level of 10 to 14 mEq/L would indicate severe acidosis, which would be life-threatening if not corrected. Both the pH and bicarbonate levels are far below their normal ranges, indicating a severe disruption in the body’s acid-base balance. In conclusion, choice A is correct because it represents values within the normal ranges for both pH and bicarbonate, indicating a resolution of ketoacidosis.
Correct Answer is D
Explanation
Step 1 is to convert the child’s weight from pounds to kilograms since the dosage is prescribed in mg/kg. We know that 1 kg is approximately 2.2 lbs. So, the child’s weight in kg is 55 lbs ÷ 2.2 = 25 kg (rounded to the nearest whole number for simplicity).
Step 2 is to calculate the total daily dosage. The prescription is for 150 mg/kg/day. So, the total daily dosage is 150 mg/kg/day × 25 kg = 3750 mg/day.
So, the correct answer is, after analysing all choices, the nurse should administer 3750 mg of cefotaxime each day.
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