Correct Answer: A

Rationale: The correct answer is 'Ineffective airway clearance.' Following a ureter lithotomy via a flank incision, the highest priority nursing problem is ensuring the client's airway remains clear. This is crucial for effective breathing and oxygenation. Altered nutrition, fluid volume excess, and activity intolerance are important to address but are of lower priority compared to maintaining a clear airway postoperatively.

Correct Answer: A

Rationale: In a 3-year-old boy presenting with dysphagia, drooling, fever, and stridor, the priority intervention should be to place the child in a mist tent. This intervention helps alleviate respiratory distress, providing immediate relief. Options B, C, and D are not as urgent as ensuring the child's airway is managed effectively. Obtaining a sputum culture, preparing for a tracheostomy, and examining the oropharynx can be done after stabilizing the child's respiratory status.

Correct Answer: C

Rationale: The correct answer is to implement seizure precautions. Phenytoin is an antiepileptic medication used for seizure control. Seizure precautions are crucial for clients taking this medication to ensure their safety during a seizure episode. Monitoring serum calcium levels (
Choice
A) is not directly related to phenytoin therapy. Obtaining a baseline electrocardiogram (
Choice
B) is important for some medications but not the priority for a client on phenytoin. Encouraging a low-protein diet (
Choice
D) is not specifically indicated for clients on phenytoin and is not the most important intervention.

Correct Answer: D

Rationale: The correct answer is D. When assessing a client diagnosed with a brain tumor, asking about seizures is crucial because they can be a common symptom associated with brain tumors. Seizures in this context could provide valuable information regarding the progression and impact of the brain tumor on the client's neurological status.

Choices A, B, and C are important questions in a general assessment, but when specifically focusing on a client with a brain tumor, inquiring about seizures takes priority due to its direct relevance to the condition.

Correct Answer: A

Rationale: The correct response is to acknowledge the client's question and open the door for further discussion by asking if they have questions about dying. This approach allows the nurse to address the client's concerns and fears, promoting open communication and providing emotional support.

Choices B and C do not encourage further dialogue about the client's feelings and concerns regarding death.
Choice D briefly acknowledges the question but does not actively invite the client to express their thoughts and emotions regarding dying.