Share This Link

This is a normal finding for the first stage of labor, which lasts until the cervix is fully dilated to 10 cm.

This is a normal finding for the active phase of the first stage of labor, which occurs when the contractions are 3 to 5 minutes apart and last for 40 to 60 seconds.

This is a normal finding that indicates the absence of infection or meconium staining in the amniotic fluid.

This is an incorrect action, as clamping the chest tube can cause a tension pneumothorax or impair lung re-expansion. The nurse should only clamp the chest tube briefly when changing the drainage system or when ordered by the provider.

This is an incorrect action, as emptying the drainage chamber can disrupt the water seal and allow air to enter the pleural space. The nurse should only empty the drainage chamber when it is full or when changing the system.

This is an incorrect action, as adding sterile water to the suction control chamber can increase or decrease the amount of suction applied to the chest tube, depending on whether water is added or removed. The nurse should only add sterile water to the water seal chamber if it falls below the 2 cm mark.

This is an expected finding for a client who has DKA, as insulin deficiency leads to hyperglycemia and glycosuria. The goal of treatment for DKA is to lower blood glucose levels gradually to prevent cerebral edema.

This is an expected finding for a client who has DKA, as insulin deficiency leads to increased breakdown of fatty acids and production of ketones, resulting in metabolic acidosis. The normal range for arterial blood pH is 7.35 to 7.45.

This is an expected finding for a client who has DKA, as metabolic acidosis causes a decrease in serum bicarbonate levels due to buffering mechanisms. The normal range for serum bicarbonate levels is 22 to 26 mEq/L.

This is an incorrect intervention, as TB requires combination therapy with multiple antitubercular medications to prevent drug resistance and ensure effective treatment. The standard regimen for TB consists of four drugs: isoniazid, rifampin, ethambutol, and pyrazinamide.

This is an intervention that is done before the diagnosis of TB is confirmed, not after. Sputum cultures for AFB are used to identify the presence of Mycobacterium tuberculosis, the causative agent of TB. Three consecutive negative sputum cultures are required to declare the client noninfectious.

This is an incorrect intervention, as surgical masks do not provide adequate protection against TB. The client should wear a high-efficiency particulate air (HEPA) respirator when outside the room, which filters out 99.97% of airborne particles.

This finding indicates that the client's nutritional status is worsening, as BUN is a waste product of protein metabolism that accumulates in the blood due to impaired renal function. A high BUN level can indicate excessive protein intake or inadequate dialysis. The normal range for BUN levels is 10 to 20 mg/dL.

This finding indicates that the client has fluid retention, not improved nutritional status. Dry weight is the weight of the client after dialysis, when all excess fluid has been removed. A weight gain of more than 1 kg above the dry weight can indicate inadequate fluid restriction or dialysis.

This finding indicates that the client has impaired renal function, not improved nutritional status. Creatinine is a waste product of muscle metabolism that accumulates in the blood due to reduced glomerular filtration rate (GFR). A high creatinine level can indicate decreased muscle mass or inadequate dialysis. The normal range for serum creatinine levels is 0.6 to 1.2 mg/dL.

This statement indicates a need for further teaching, as limiting sodium intake to 4 grams per day is not sufficient for someone with hypertension. The recommended daily sodium intake for individuals with hypertension is generally lower, around 1,500-2,300 milligrams (mg).

While limiting caffeine intake is generally recommended for individuals with hypertension, this statement does not address other lifestyle modifications specifically related to blood pressure.

Regular exercise is beneficial for overall health, but the frequency and duration mentioned in this statement may not be sufficient for effectively lowering blood pressure. The American Heart Association recommends at least 150 minutes of moderate-intensity aerobic exercise or 75 minutes of vigorous-intensity exercise per week for individuals with hypertension.