Correct Answer: C

Rationale: The correct answer is C: Report sudden onset of acute pain. This is the highest priority because sudden onset of acute pain postoperatively can indicate a serious complication such as hemorrhage or infection. Prompt reporting allows for timely intervention to prevent further complications.

A: Do not leave the patient unattended at any time - While important for safety, it is not the highest priority compared to addressing sudden onset of acute pain.
B: Teach the patient not to bend over - Important for preventing complications postoperatively, but not as urgent as addressing sudden onset of acute pain.
D: Apply sandbags to either side of the head - This intervention is not typically indicated for postoperative eye patients and would not address the potential serious complication of sudden onset of acute pain.

Correct Answer: B

Rationale: The correct answer is B because it provides a specific action (offering water) at regular intervals (every 2 hours) to promote hydration, which is a clear and measurable nursing intervention.
Choice A is too prescriptive and lacks flexibility.
Choice C is reactive and not proactive.
Choice D is vague and lacks specific guidance on how to achieve the desired outcome. By offering water consistently, the nurse ensures proactive care and helps meet the client's hydration needs effectively.

Correct Answer: B

Rationale: The correct answer is B: “Rotate injection sites within the same anatomic region, not among different regions.” This instruction is important to prevent lipodystrophy and ensure consistent insulin absorption. Rotating sites within the same region helps maintain consistent insulin absorption rates and reduces the risk of developing scar tissue or fatty deposits. Injecting into healthy tissue with large blood vessels and nerves (choice
A) can lead to inconsistent absorption. Administering insulin into areas of scar tissue or hypotrophy (choice
C) can also disrupt absorption. Injecting into sites above muscles planned for exercise (choice
D) can lead to unpredictable insulin absorption. Rotation within the same region optimizes insulin delivery and prevents complications.

Correct Answer: B

Rationale: The correct answer is B: Communicating the client’s progress to the interdisciplinary team. During the evaluation phase, the nurse plays a crucial role in ensuring continuity of care by effectively communicating the client’s progress to the interdisciplinary team. This action allows for collaborative decision-making based on the latest information, promotes coordination of care, and ensures that all team members are informed and involved in the client's care plan. Rewriting the care plan (
A) is important but may not be the most immediate action during the evaluation phase. Reassessing the client (
C) is valuable for gathering additional data but may not directly contribute to continuity of care during this phase. Providing emotional support (
D) is essential but may not specifically address continuity of care during evaluation.

Correct Answer: C

Rationale: The correct answer is C: Fluid replacement. In end-stage AIDS with Cryptosporidium infection, the client experiences severe diarrhea leading to dehydration and electrolyte imbalances. Fluid replacement is crucial to prevent hypovolemia and maintain electrolyte balance. Adequate hydration supports renal function, prevents further complications, and aids in the elimination of the infectious agent. Pain management (
A) may be needed for discomfort but is not the priority. Antiretroviral therapy (
B) is essential for managing HIV but does not directly address the immediate issue of dehydration. High-calorie intake (
D) is important for overall nutrition but does not address the urgent need for fluid replacement in this situation.