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The nurse is admitting a client who reports symptoms of dyspnea. The nurse notes edema of the upper arms, face, and neck. What is the nurse's priority assessment?

A.

Degree of upper body vasculature observed.

B.

Arm circumference and degree of edema.

C.

Blood pressure and heart rate.

D.

Peripheral sensation and movement of upper extremities.

Answer and Explanation

The Correct Answer is C

A. Assessing the degree of upper body vasculature may provide some information, but it does not directly address the client's current symptoms or vital status.  

 

B. Measuring arm circumference and evaluating the degree of edema are important for understanding the extent of swelling but do not assess the client’s hemodynamic stability or respiratory status.  

 

C. Blood pressure and heart rate are critical assessments in this scenario, especially considering the client’s dyspnea and upper body edema. Changes in these vital signs can indicate potential respiratory distress, compromised cardiac function, or anaphylaxis, which requires immediate intervention.  

 

D. While assessing peripheral sensation and movement is important for overall neurological function, it is not a priority in this context compared to assessing vital signs that can directly affect the client’s stability.


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View Related questions

Correct Answer is B

Explanation

A. 1500: This is incorrect

B. The calculation is as follows:

Remaining fluid: 600 mL
IV rate: 100 mL/hour

Time to empty the bag: 600 mL ÷ 100 mL/hour = 6 hours

Adding 6 hours to the report time:
0700 + 0600 = 1300

The correct answer is 1300.

C. 1400: This is incorrect

D. 1500: This is incorrect

Correct Answer is C

Explanation

A. A history of Roux-en-Y gastric bypass surgery is not a direct risk factor for colorectal cancer; in some cases, it may reduce risk due to weight loss and dietary changes.

B. A high fiber, low fat diet is considered protective against colorectal cancer rather than a risk factor.

C. A personal history of inflammatory bowel disease, such as ulcerative colitis or Crohn's disease, significantly increases the risk for developing colorectal cancer due to chronic inflammation and cellular changes in the colon.

D. Having a distant relative with colorectal cancer may increase risk, but the personal history of inflammatory bowel disease is a stronger risk factor warranting emphasis in teaching.

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