Correct Answer: D

Rationale: The correct answer is D because a class V Pap test finding indicates severe abnormalities, such as high-grade dysplasia or carcinoma in situ. Therefore, the nurse should instruct the client to undergo a biopsy as soon as possible to confirm the diagnosis and initiate appropriate treatment promptly. Choices A, B, and C are incorrect because a class V result is not normal and requires immediate follow-up, rather than waiting or repeating the Pap test at a later time.

Correct Answer: A

Rationale: The correct answer is A. Before administering a narcotic analgesic like Morphine, assessing the client's level of alertness and respiratory rate is crucial to ensure they can tolerate the medication without compromising their breathing. Alertness indicates their ability to handle potential side effects, while respiratory rate is vital to monitor for any signs of respiratory depression. Choice B (last meal) is not directly related to giving a narcotic analgesic, although it may impact the absorption rate. Choice C (bowel habits) and last bowel movement are not immediately relevant to assessing the client's readiness for a narcotic analgesic. Choice D (history of addictions) is important but not the priority when assessing for immediate safety and efficacy of the medication.

Correct Answer: C

Rationale: The correct answer is C: “This type of surgery rarely affects the ability to have an erection or ejaculation.” This response is appropriate because it provides accurate information that addresses the patient's concern about sexual function without making any false claims. TURP (Transurethral Resection of the Prostate) typically does not impact a patient's ability to have an erection or ejaculate. This reassurance can help alleviate the patient's fears and provide him with accurate information to make an informed decision. Explanation for why the other choices are incorrect: A: “Don’t worry about sterility; sperm production is not affected by this surgery.” - This is incorrect as the concern is more about sexual function than sterility. B: “Would you like some information about implants used for impotence?” - This is incorrect as it jumps to a solution without addressing the patient's specific concern about TURP affecting sexual function. D: “There are many methods of sexual expression that are alternatives to sexual intercourse

Correct Answer: A

Rationale: The correct answer is A: Diet and exercise program. This is because a client's diet and exercise program directly impact their physical health and well-being, making it an important factor to consider when determining assessment priorities. Understanding their dietary habits and level of physical activity can help identify potential health risks or areas for improvement. Choices B, C, and D are incorrect because they do not directly relate to the client's physical health and well-being, which are crucial factors in determining assessment priorities. Standing in the community (B) may influence social interactions but does not necessarily impact assessment priorities. Ability to pay for services (C) relates to financial considerations rather than health assessment priorities. Developmental stage (D) may be important for understanding the client's cognitive and emotional development, but it is not as directly relevant to assessment priorities as diet and exercise.

Correct Answer: C

Rationale: The correct answer is C: Observe wound appearance and edges. This is the first intervention the nurse should perform because assessing the wound's appearance and edges provides crucial information about the healing process and any signs of infection. It helps in determining the next steps in the care plan. Reinforcing the dressing (A) and performing dressing changes (B) should come after assessing the wound. Documenting wound characteristics (D) is important but should also follow the initial assessment.