For correct answer choice:

Prothrombin time is correct. It is a crucial test that measures how long it takes for blood to clot and assesses the coagulation pathway. Evaluating PT is particularly important before surgical procedures to assess the risk of bleeding.

For incorrect answer choices:

Fibrinogen level is incorrect. Although it is an important test related to coagulation since it is a key protein involved in blood clot formation, it is not the primary test to assess coagulation status before a biopsy.

International normalized ratio is incorrect. While it is derived from the PT and provides a standardized way to evaluate coagulation status, especially in patients on anticoagulant therapy—it is not the most direct test compared to PT for assessing the risk of bleeding before surgery.

Serum creatinine is incorrect. This test measures kidney function and is not directly related to coagulation status. While it is essential for overall health assessment, it does not evaluate the blood's ability to clot.

For correct answer choice:

Measure the wellbeing of the fetus is correct. The primary purpose of a nonstress test is to measure the wellbeing of the fetus by evaluating the fetal heart rate in response to fetal movements. An NST helps determine if the fetus is receiving enough oxygen and nutrients, which is critical given the patient's history of stillborn infants.

For incorrect answer choices:

Assess the cervical dilation progress is incorrect. Assessing cervical dilation is not a function of an NST; cervical assessments are performed through a different evaluation process during labor.

Evaluate fetal lung maturity is incorrect. Evaluating fetal lung maturity is typically assessed through other means, such as amniotic fluid analysis, and is not directly determined through a nonstress test.

Monitor maternal blood pressure changes is incorrect. Monitoring maternal blood pressure changes is not the focus of an NST, which is primarily concerned with fetal heart rate patterns and movements.

For correct answer choice:

Assess the patient's vital signs every 15 minutes for the first hour is correct. Close monitoring of vital signs is essential to detect any changes that may indicate complications such as bleeding, hypotension, or arrhythmias following a cardiac catheterization.

For incorrect answer choices:

Initiate a diet high in fiber to promote bowel function is incorrect as the priority. Although bowel function is important, it is not the primary concern immediately after the procedure; monitoring vital signs takes precedence.

Prepare the patient for a chest x-ray to assess lung status is incorrect. While lung assessment is important, it is not necessary immediately after a cardiac catheterization unless there are specific indications of respiratory issues.

Encourage the patient to ambulate within 2 hours of the procedure is incorrect. Early ambulation is beneficial but should not occur until the patient is stable and adequately monitored for complications.

For correct answer choice:

Hemorrhagic shock is correct. The combination of restlessness, tachycardia, and hypotension is highly suggestive of hemorrhagic shock, indicating a significant loss of blood volume that impairs perfusion and oxygen delivery to tissues.

For incorrect answer choices:

Pulmonary embolism is incorrect. Although it can cause similar symptoms, typically, pulmonary embolism presents with sudden onset shortness of breath and chest pain, along with hypoxemia. While they can lead to hypotension, restlessness, and tachycardia, they are more indicative of an acute volume loss rather than a sudden obstruction in the pulmonary circulation.

Hypoglycemia is incorrect. While hypoglycemia can cause tachycardia and restlessness, it is less likely to cause hypotension, especially in the context of a postoperative patient, where hemorrhage is a more common concern.

Gastrointestinal perforation is incorrect, although it can lead to shock. It typically presents with severe abdominal pain and signs of peritonitis rather than restlessness and a sudden drop in blood pressure without abdominal symptoms.

For correct answer choice:

Increased serum calcium is correct. This finding is characteristic of primary hyperparathyroidism due to the overproduction of parathyroid hormone (PTH), which leads to the mobilization of calcium from bones and increased absorption from the intestines and kidneys.

For incorrect answer choices:

Decreased serum magnesium is incorrect. This is not specifically associated with primary hyperparathyroidism; magnesium levels can fluctuate independently of calcium levels and may even be normal or elevated in this condition.

Increased serum bicarbonate is incorrect. This is not a typical finding in primary hyperparathyroidism and does not relate to calcium metabolism. Acid-base balance is generally unaffected by the disease.

Decreased serum sodium is incorrect. Sodium levels are usually unaffected in primary hyperparathyroidism unless there are other underlying issues present.

For correct answer choice:

Cardiac catheterization is correct. It is the most effective method for identifying specific areas of damage in the myocardium, allowing for direct assessment of coronary artery status and blood flow to the heart muscle.

For incorrect answer choices:

Echocardiogram is incorrect. While it provides valuable information about heart function and structure, such as wall motion abnormalities, it is less precise for pinpointing the exact location of myocardial damage compared to cardiac catheterization.

Holter monitor is incorrect. This tool is used for continuous monitoring of heart rhythms over a period of time but does not assess myocardial damage or its location.

Complete blood count (CBC) is incorrect. It offers general information about the patient’s overall health and the presence of infection or anemia but is not specific for assessing myocardial damage.

For correct answer choice:

High levels of both corticotropin and cortisol is correct. In Cushing's disease, caused by a corticotropin-secreting pituitary adenoma, the increased secretion of ACTH stimulates the adrenal glands to produce excess cortisol, resulting in elevated levels of both hormones.

For incorrect answer choices:

Low levels of corticotropin and high levels of cortisol is incorrect. This pattern suggests an adrenal source of cortisol (such as an adrenal adenoma) rather than a pituitary cause, which would not support the diagnosis of a corticotropin-secreting adenoma.

Normal corticotropin levels and low cortisol levels is incorrect. This profile would not be indicative of Cushing’s disease or a pituitary adenoma; it suggests adrenal insufficiency or a non-functioning pituitary.

Low levels of both corticotropin and cortisol is incorrect. This finding does not align with the pathophysiology of Cushing’s disease and would suggest adrenal insufficiency or pituitary failure.

For correct answer choice:

Carcinoembryonic antigen is correct. It is often elevated in smokers, reflecting the body’s response to irritation or inflammation rather than serving as a specific cancer diagnosis marker. This makes it unreliable as a general indicator of cancer.

For incorrect answer choices:

Prostate-specific antigen is incorrect. PSA is specifically used to screen for prostate cancer and may be elevated due to benign prostatic hyperplasia (BPH), but it is not directly associated with smoking.

Serum calcium level is incorrect. It does not directly correlate with smoking status and is not typically elevated due to smoking; rather, it can indicate other health issues.

Thyroid-stimulating hormone is incorrect. TSH levels are used to evaluate thyroid function and are not influenced by smoking, nor do they indicate cancer risk.

For correct answer choice:

Increased respiratory effort is correct. Increased respiratory effort can indicate respiratory distress and may suggest organ rejection in lung transplant patients, as it may be associated with reduced lung function or pulmonary complications.

For incorrect answer choices:

Mild fever is incorrect. Although a mild fever can indicate infection or rejection, it is a non-specific finding and not as strongly indicative of rejection compared to changes in respiratory status.

Weight gain is incorrect. Weight gain can be due to fluid retention or other factors but does not specifically indicate rejection. It is not a direct marker for transplant rejection.

Peripheral edema is incorrect. While peripheral edema can occur for various reasons, including fluid overload or heart issues, it is not a strong indicator of lung transplant rejection. It may not be directly related to the lung function.

For correct answer choice:

Normal; the Paco2 level is within the expected range is correct. This value falls within the normal range (35 to 45 mm Hg) for arterial blood gases, indicating that the patient’s ventilation is adequate.

For incorrect answer choices:

Significant; indicates hypoventilation and potential respiratory distress is incorrect. It does not suggest hypoventilation; typically, hypoventilation would manifest as a Paco2 greater than 45 mm Hg.

Appropriate; indicates a compensatory mechanism for metabolic acidosis is incorrect. It does not indicate a compensatory mechanism for metabolic acidosis; compensatory mechanisms would require other abnormal lab values to support that condition.

Concerning; requires immediate intervention to correct hypoxia is incorrect. There is no evidence of hypoxia based solely on the Paco2 value, and intervention is not necessary at this level.

For correct answer choice:

CT scan is correct. It is the definitive diagnostic test for abdominal aortic aneurysm, providing high-resolution images that can effectively identify the size and morphology of the aneurysm.

For incorrect answer choices:

Transesophageal echocardiogram is incorrect. This test is primarily used for cardiac assessments and is not typically utilized for diagnosing AAA. While it can visualize parts of the aorta, it lacks specificity for detecting aneurysms.

Plain abdominal radiography is incorrect. This imaging may indicate an aneurysm through indirect signs, such as calcification, but it cannot confirm the presence or size of an AAA.

Peripheral angiography is incorrect. This diagnostic tool is more relevant for assessing blood flow in the peripheral arteries and does not provide the comprehensive visualization of the abdominal aorta needed to confirm an AAA.

For correct answer choice:

Stop the transfusion immediately is correct. The priority action is to stop the transfusion to prevent further reaction and protect the patient. This is essential in the event of a transfusion reaction, which can escalate rapidly.

For incorrect answer choices:

Notify the healthcare provider is incorrect as the first step. While it is important to notify the provider after stopping the transfusion, immediate action to halt the transfusion takes precedence to ensure patient safety.

Administer antihistamines as ordered is incorrect in this context. While antihistamines may be indicated for allergic reactions, the priority is to stop the transfusion before administering any medications.

Take vital signs and document findings is incorrect as the first action. Although monitoring vital signs is important, it should be done after stopping the transfusion to assess the patient's response and guide further interventions.

For correct answer choice:

A positive result for anti-dsDNA antibodies is correct. This laboratory finding is highly associated with systemic lupus erythematosus (SLE) and is considered a specific marker for the disease, aiding in the confirmation of the diagnosis alongside clinical findings.

For incorrect answer choices:

Elevated C-reactive protein (CRP) is incorrect. While this indicates inflammation, it is not specific to SLE and can be elevated in a range of conditions, including infections and other inflammatory diseases.

Increased levels of serum electrolytes is incorrect. This finding does not specifically indicate SLE and may be related to various other underlying issues unrelated to the autoimmune process.

A low platelet count is incorrect. Although this may occur in SLE due to immune-mediated destruction or other factors, it is not specific to the disease and does not serve as a definitive diagnostic indicator.

For correct answer choice:

Blood pressure monitoring is correct. Nitroglycerin can cause vasodilation and result in hypotension. Frequent blood pressure monitoring is essential to ensure patient safety and adjust the medication dosage as needed.

For incorrect answer choices:

Auscultation of lung sounds is incorrect as the primary focus. While lung sounds may be assessed to monitor for signs of heart failure or pulmonary edema, they are not as critical to monitor frequently compared to blood pressure in a patient receiving nitroglycerin.

Assessment of peripheral pulses is incorrect. Although assessing peripheral circulation is important, it is less critical than monitoring blood pressure in the context of nitroglycerin therapy.

Evaluation of serum glucose levels is incorrect as it is not directly related to nitroglycerin therapy. While monitoring glucose is important for overall patient management, it is not a priority in this scenario.

For correct answer choice:

Hyperkalemia is correct. It is a common finding in patients experiencing an Addisonian crisis due to insufficient production of aldosterone. Aldosterone normally helps regulate potassium levels, and when it is low, potassium is retained, leading to elevated serum potassium levels.

For incorrect answer choices:

Hypokalemia is incorrect. It is unlikely in an Addisonian crisis; the opposite is true, as aldosterone deficiency causes potassium retention rather than excretion.

Hypoglycemia is incorrect. Although hypoglycemia can occur in an Addisonian crisis due to inadequate cortisol levels, hyperkalemia is a more distinctive and expected laboratory finding in this condition.

Hyponatremia is incorrect. While hyponatremia is common due to the lack of aldosterone, hyperkalemia is more characteristic and critical to monitor during an acute crisis.

For correct answer choice:

Assess for signs of infection at the incision site is correct. Given the patient's recent surgery and the symptoms of fever, tachycardia, and localized tenderness, the priority action is to assess the incision site for redness, swelling, discharge, or other signs of infection. Early identification of an infection can lead to timely intervention.

For incorrect answer choices:

Administer the prescribed pain medication is incorrect as the immediate priority is to assess the patient for potential complications, particularly infection, rather than treating pain, which may or may not be related to the current symptoms.

Encourage the patient to ambulate in the hallway is incorrect in this context. While ambulation is important for recovery, it is not the immediate priority if the patient exhibits signs that may indicate a complication.

Notify the surgeon of the patient’s symptoms is also incorrect as a first step. Although it may ultimately be necessary to inform the surgeon, the nurse should first gather information by assessing the patient thoroughly.

For correct answer choice:

Arterial blood gas (ABG) showing pH 7.32 and PaCO2 55 mmHg is correct. This result indicates respiratory acidosis, characterized by a low pH (indicating acidosis) and an elevated PaCO2 (indicating hypoventilation and inadequate carbon dioxide elimination).

For incorrect answer choices:

Arterial blood gas (ABG) showing pH 7.45 and PaCO2 40 mmHg is incorrect. This represents a normal pH and PaCO2 level, indicating neither acidosis nor alkalosis.

Arterial blood gas (ABG) showing pH 7.48 and PaCO2 30 mmHg is incorrect. This indicates respiratory alkalosis, characterized by a high pH and low PaCO2 due to hyperventilation.

Arterial blood gas (ABG) showing pH 7.40 and PaCO2 45 mmHg is incorrect. This result is within normal limits, indicating neither acidosis nor alkalosis and suggests stable respiratory function.

For correct answer choice:

The patient has a cochlear implant is correct. A cochlear implant can be affected by the strong magnetic fields generated by an MRI, potentially causing damage to the implant or injury to the patient. Therefore, it is considered a contraindication for MRI.

For incorrect answer choices:

The patient has a history of high blood pressure is incorrect. While high blood pressure should be monitored, it is not a contraindication for an MRI, and patients with controlled hypertension can safely undergo the procedure.

The patient is on medication for diabetes is incorrect. Being on medication for diabetes does not affect the ability to undergo an MRI, although it is essential to manage the patient's condition appropriately before and after the procedure.

The patient has a family history of kidney disease is incorrect. This factor does not contraindicate an MRI. However, if contrast dye is used during the procedure, renal function should be evaluated to avoid complications, but this does not prevent the MRI itself.

For correct answer choice:

Notify the physician regarding the high output is correct. A chest tube output of 300 mL per hour can indicate potential complications such as bleeding or fluid accumulation. Immediate medical evaluation may be necessary to address the patient's safety.

For incorrect answer choices:

Check the chest tube for kinks or obstructions is incorrect. Checking the chest tube for kinks or obstructions is incorrect as a first action. While maintaining the chest tube’s patency is important, it is secondary to the urgent need to address the clinical significance of the high output.

Document the output in the patient’s chart is incorrect. Although documenting is essential for medical records, it does not address the immediate concern of excessive drainage and its implications for patient safety.

Position the patient in a high Fowler’s position is incorrect. While this position may assist with breathing, it does not address the urgent need to evaluate the excessive drainage, which could indicate a serious complication.

For correct answer choice:

Feet is correct. In right-sided congestive heart failure, fluid retention commonly leads to peripheral edema, which is most pronounced in the feet and lower extremities. Therefore, the nurse should primarily assess these areas for the extent of swelling.

For incorrect answer choices:

Abdomen is incorrect. While abdominal swelling can occur due to fluid accumulation, it is not the first area to evaluate for peripheral edema in right-sided heart failure. The feet are more indicative of fluid retention.

Hands is incorrect. Although hands can show signs of edema, they are less commonly the primary focus in this context compared to the feet, where fluid accumulation is more evident.

Neck is incorrect. While the neck may exhibit signs of edema, such as jugular venous distension, the feet are the most reliable area for detecting peripheral edema associated with right-sided heart failure.