Share This Link

Checking the surgical dressing for bleeding detects postoperative hemorrhage, which can lead to hypovolemia. However, in the immediate post-extubation period, airway and breathing take precedence, as respiratory compromise is more life-threatening than bleeding, which can be addressed after ensuring oxygenation.

Assessing pain is important for comfort and recovery, as pain increases stress hormones and cardiac workload. However, post-extubation, respiratory status is the priority, as anesthesia effects or airway obstruction can cause hypoxia, a more immediate threat than pain in the PACU.

Examining the IV site for redness or infiltration ensures proper medication delivery and prevents complications like phlebitis. However, this is secondary to respiratory assessment post-extubation, as airway obstruction or hypoventilation poses a greater immediate risk to life than IV site issues.

Sickle cell disease is a genetic hemoglobinopathy causing hemolytic anemia, not iron deficiency anemia. It involves abnormal hemoglobin, not low iron, leading to red cell sickling and hemolysis. This condition does not impair iron absorption or storage, making it unrelated to iron deficiency anemia.

Leukemia causes anemia through bone marrow suppression, producing normocytic or macrocytic anemia, not microcytic iron deficiency anemia. It affects red cell production broadly, not iron metabolism specifically, making it less relevant to iron deficiency compared to dietary or blood loss causes.

A bleeding ulcer causes chronic blood loss, depleting iron stores and leading to iron deficiency anemia. While a significant cause, the question emphasizes dietary correlation, making a meat-free diet more directly relevant, as it consistently limits iron intake, contributing to anemia development.

Calf tenderness and swelling in polycythemia vera suggest possible deep vein thrombosis due to hyperviscosity from increased red blood cell mass, promoting clot formation. This increases the risk of pulmonary embolism, but it is less immediately life-threatening than acute respiratory distress, as it primarily affects venous circulation rather than immediate oxygenation.

A swollen, painful great toe may indicate gout in polycythemia vera, caused by elevated uric acid from increased cell turnover. This localized inflammatory condition causes discomfort but is not life-threatening. It requires management with anti-inflammatory agents, but it is less urgent than symptoms indicating potential cardiopulmonary complications.

A blood pressure of 180/98 mm Hg indicates hypertension, common in polycythemia vera due to increased blood viscosity and volume. While this increases cardiovascular risk, it is less urgent than shortness of breath, which signals immediate hypoxia. Hypertension requires monitoring and management but does not pose an immediate threat to life.

Audible wheezes and dyspnea suggest asthma or COPD, where bronchoconstriction narrows airways, causing wheezing and shortness of breath. In cystic fibrosis, thick mucus primarily causes airway obstruction, leading to chronic infections and congestion rather than prominent wheezing, which is less specific to this condition.

Difficulty breathing when speaking, dyspnea, and chronic cough are seen in many respiratory conditions, including COPD or chronic bronchitis. While cystic fibrosis involves chronic cough, these symptoms alone are not specific, as cystic fibrosis also includes gastrointestinal symptoms like malabsorption, which are absent in this choice.

Sudden absence of wheezing and low SpO2 suggest a critical airway obstruction or pneumothorax, not typical of cystic fibrosis. In cystic fibrosis, chronic mucus buildup causes persistent symptoms, not sudden resolution of wheezing. Low SpO2 may occur, but the sudden change is more indicative of acute conditions.

Coordination involves organizing care among team members, but SBAR (Situation, Background, Assessment, Recommendation) specifically structures information exchange to ensure clarity and efficiency. While coordination benefits indirectly, SBAR’s primary role is to standardize verbal or written communication, reducing errors in conveying critical patient data during interdisciplinary interactions.

Supervision entails overseeing tasks performed by others, ensuring adherence to standards. SBAR does not directly facilitate supervision but rather provides a framework for clear communication of patient status. It ensures supervisors receive accurate information but is not a tool for managing or directing staff activities.

Delegation involves assigning tasks to appropriate personnel. SBAR does not directly manage task delegation but supports it by clearly communicating patient needs, which may inform delegation decisions. Its primary function is to ensure accurate information transfer, not to oversee the assignment or execution of tasks.

The nurse is not required to perform delegated tasks alongside the CNA. Delegation involves assigning tasks within the CNA’s scope, such as I&O measurement, while the nurse oversees and verifies outcomes. Performing the task together negates the purpose of delegation, which is to distribute workload efficiently.

The nurse must follow up on delegated tasks to ensure accuracy and patient safety. Assuming the CNA’s competence without verification risks errors in I&O documentation, which can affect fluid balance management in cardiac patients, potentially leading to complications like heart failure exacerbation.

While ensuring CNA competence is important, the primary principle is accountability. The nurse must confirm the CNA’s ability before delegation but remains responsible for the task’s outcome. Competence assessment is a prerequisite, but accountability encompasses ongoing oversight and responsibility for the delegated task’s execution.

Dependent edema is more characteristic of right-sided heart failure, where systemic venous congestion causes fluid accumulation in lower extremities. In left-sided heart failure, pulmonary congestion predominates, leading to respiratory symptoms rather than peripheral edema, which is less directly associated with left ventricular dysfunction.

Jugular vein distention reflects right-sided heart failure, where increased venous pressure from right ventricular failure causes neck vein engorgement. Left-sided heart failure primarily affects pulmonary circulation, leading to lung congestion rather than systemic venous changes, making this finding less expected in this condition.

Polyuria at night (nocturia) is associated with conditions like benign prostatic hyperplasia or diabetes, not left-sided heart failure. In heart failure, reduced cardiac output may decrease renal perfusion, leading to oliguria rather than increased urine output, especially during exacerbation of left-sided failure.

Hyperkalemia (high potassium) is unlikely in Clostridium difficile diarrhea, as significant fluid and electrolyte loss occurs. Potassium is lost in watery stools, reducing serum levels. Hyperkalemia is more associated with renal failure or tissue breakdown, where potassium release exceeds excretion, not diarrhea-related losses.

Hypocalcemia (low calcium) is less common in diarrhea, as calcium loss is minimal compared to potassium or sodium. Clostridium difficile primarily causes fluid and electrolyte losses, with potassium and sodium being more significantly affected due to their higher concentration in intestinal secretions.

Hyponatremia (low sodium) can occur in diarrhea due to sodium loss in stools. However, potassium loss is more pronounced in Clostridium difficile infections, as watery diarrhea depletes potassium faster, making hypokalemia the primary concern, especially given its impact on cardiac and muscle function.