A client is in the hospital and has received two doses of an angiotensin-converting enzyme for hypertension. When the nurse answers the client's call light, the client presents an appearance as shown below: What action by the nurse takes is most appropriate?

Correct Answer: C

Rationale: The correct answer is C: Ensure a patent airway while calling the Rapid Response Team. This is the most appropriate action because the client is showing signs of angioedema, a potentially life-threatening adverse reaction to angiotensin-converting enzyme (ACE) inhibitors. Angioedema can lead to airway obstruction and respiratory distress, so ensuring a patent airway is crucial. Calling the Rapid Response Team will provide immediate access to additional resources and expertise to manage the situation effectively. Choice A (Administer epinephrine) is incorrect because epinephrine is not the first-line treatment for angioedema caused by ACE inhibitors. Choice B (Apply oxygen) may be helpful but does not address the urgent need to secure the airway. Choice D (Reassure the client) is inappropriate as the situation requires immediate intervention to prevent respiratory compromise.

Correct Answer: A

Rationale: Neutrophils are not antigen presenting cells as they primarily function in innate immunity by phagocytosing pathogens. B cells, macrophages, and dendritic cells are antigen presenting cells that process and present antigens to activate adaptive immune responses. Neutrophils lack the specialized machinery for antigen presentation, making choice A the correct answer.

Correct Answer: B

Rationale: The correct answer is B: "Have you been camping in the last month?" This question is the first one to ask because the client presenting with a ring-like rash on the upper leg suggests a possible exposure to ticks, which are commonly found in outdoor environments like camping areas. Ticks can transmit Lyme disease, which often presents with a characteristic rash called erythema migrans. By asking about recent camping activities, the nurse can gather crucial information to assess the likelihood of a tick bite and the need for further evaluation or treatment. Choices A, C, and D are incorrect because they do not directly address the potential exposure to ticks from outdoor activities like camping. Asking about cats in the home (choice A) is more relevant for conditions like cat scratch fever. Inquiring about flu-like symptoms (choice C) and physical contact with others with a similar rash (choice D) may be important but are not as pertinent as determining outdoor activities that could lead to a tick bite.

Correct Answer: C

Rationale: The correct answer is C: Serum amylase level. Elevated serum amylase levels indicate pancreatic toxicity, a known adverse effect of didanosine. The nurse should be concerned as this can lead to pancreatitis. Discontinuation of the medication is necessary to prevent further complications. A: Serum protein level is not directly related to didanosine toxicity. B: Blood glucose level is not typically affected by didanosine. D: Serum creatinine level is not typically affected by didanosine and does not indicate the need for discontinuation of the medication.

Correct Answer: B

Rationale: The correct answer is B: Vitamin B12 deficiency. This patient presents with symptoms of ataxia, paresthesias, macrocytic anemia, and hypersegmented neutrophils, which are classic signs of B12 deficiency. The prior gastrectomy suggests impaired intrinsic factor production, leading to malabsorption of B12. Folic acid deficiency (Choice A) can also cause macrocytic anemia but does not typically present with neurological symptoms. Vitamin K deficiency (Choice C) leads to bleeding disorders, not neurological symptoms. Iron deficiency (Choice D) results in microcytic anemia and does not explain the neurological findings in this patient.