Correct Answer: A

Rationale: The correct answer is A because narcotics in high doses can depress the respiratory rate and cough reflex, which can be especially dangerous for a laryngectomy patient due to the risk of airway compromise. Low doses can provide pain relief without significant respiratory depression.

Choices B and C are incorrect because narcotics typically do not increase respiratory tract secretions or cause stomal edema.
Choice D is incorrect because while narcotics can potentially cause addiction, this is not the primary reason for giving low doses to laryngectomy patients.

Correct Answer: C

Rationale: The correct answer is C: Call the physician. In this scenario, the sudden severe headache and nasal congestion along with flushed skin and goosebumps suggest autonomic dysreflexia, a medical emergency in spinal cord injury at or above T6. The nurse should immediately call the physician to address this potentially life-threatening situation. Raising the client's head (
A) may worsen the condition, placing the client on a firm mattress (
B) is not a priority, and administering an analgesic (
D) without addressing the underlying cause could lead to further complications. The priority is to identify and address the cause of autonomic dysreflexia promptly.

Correct Answer: A

Rationale: The correct answer is A: A urine output of 400 ml in 8 hours indicates a fluid and electrolyte imbalance induced by chemotherapy. Chemotherapy can cause renal damage, leading to decreased urine output. This can result in fluid retention and electrolyte imbalances.


Choice B is incorrect because a serum potassium level of 3.6 mEq/L is within the normal range.
Choice C is incorrect as the blood pressure readings provided are within the normal range.
Choice D is incorrect as dry oral mucous membranes and cracked lips are more indicative of dehydration rather than a fluid and electrolyte imbalance induced by chemotherapy.

Correct Answer: B

Rationale: The correct answer is B because during the evaluation phase of nursing care for a client with COPD, the nurse should review the client's progress toward meeting the goals set during the planning phase. This involves assessing whether the interventions implemented are effective in improving the client's condition and if the goals are being achieved. This step is crucial in determining the overall effectiveness of the care provided and making any necessary adjustments to the plan.

A: Documenting interventions is important but not the primary focus during the evaluation phase.
C: Delegating further care is not typically done during the evaluation phase as it is more about assessing the current care plan.
D: Ensuring compliance with physician orders is important but does not encompass the holistic evaluation of the client's progress towards goals.

Correct Answer: A

Rationale: The correct answer is A: Liver. The liver is a common site for metastasis because it receives blood from various organs, making it a prime location for cancer cells to travel and establish secondary tumors. Additionally, the liver has a rich blood supply and provides a favorable environment for cancer cells to thrive. In contrast, B (Reproductive tract) and C (Colon) are not as common sites for metastasis compared to the liver.
Choice D (White blood cells) is incorrect as metastasis involves the spread of cancer cells to distant organs, not within the blood cells themselves.