A client with stage II ovarian cancer undergoes a total abdominal hysterectomy and bilateral salpingo- oopherectomy with tumor secretion, omentectomy, appendectomy, and lymphadenopathy. During the second postoperative day, which of the following assessment findings would raise concern in the nurse?

Correct Answer: D

Rationale: The correct answer is D - Shallow breathing and increasing lethargy. This could indicate a potential complication such as respiratory distress or postoperative infection. Shallow breathing may suggest respiratory compromise, while increasing lethargy could be a sign of systemic infection or inadequate oxygenation. A: Abdominal pain is common postoperatively and can be managed with pain medication. B: Serous drainage from the incision is normal and expected in the early postoperative period. C: Hypoactive bowel sounds are common after abdominal surgery due to anesthesia and manipulation of the bowel; it typically resolves as the patient recovers. In summary, the other options are common postoperative findings, while shallow breathing and increasing lethargy are concerning signs that require immediate attention.

Correct Answer: C

Rationale: The correct answer is C: Cooked vegetables. Cooking vegetables helps to kill harmful bacteria and parasites that may pose a risk of infection to an immunocompromised individual like a patient with HIV. Raw fruits (A) and raw vegetables (B) may carry pathogens that can be dangerous for someone with a weakened immune system. Caesar dressing (D) may contain raw eggs, which also pose a risk for infection. Therefore, choosing cooked vegetables is the safest option to reduce the risk of infection for the patient with HIV.

Correct Answer: A

Rationale: The correct answer is A. In the Snellen eye chart test, the first number (20) represents the distance at which the client is viewing the chart, and the second number (40) represents the distance at which a person with normal vision can read the same line. Therefore, a client with 20/40 vision sees letters at 20 feet that others with normal vision can read at 40 feet. Choices B, C, and D are incorrect because they do not accurately reflect the interpretation of the 20/40 vision result from the Snellen eye chart test. B is incorrect because the client does not see letters at 40 feet that others can read at 20 feet. Choices C and D are incorrect because the Snellen eye chart test measures visual acuity, not color perception.

Correct Answer: D

Rationale: The correct answer is D: anorexia. In the early stage of hepatic inflammatory disorder, anorexia is the most likely symptom/sign. This is because hepatic inflammation can lead to a decrease in appetite, resulting in anorexia. Dark urine (A) is commonly associated with liver dysfunction but typically occurs later in the disease process. Occult blood in stools (B) is more indicative of gastrointestinal bleeding rather than early hepatic inflammation. Ascites (C) is the accumulation of fluid in the abdominal cavity and is a later manifestation of liver disease. Therefore, anorexia is the most likely symptom in the early stages of hepatic inflammatory disorder.

Correct Answer: D

Rationale: The correct answer is D: Malnutrition. Malnutrition weakens the immune system, making individuals more susceptible to contracting tuberculosis. A well-nourished individual has a stronger immune response to fight off TB bacteria. Exposure to toxic gases (A), congenital abnormalities (B), and obstruction by tumor (C) do not directly predispose a client to TB. Malnutrition is the key factor as it impairs the immune system's ability to combat the TB bacteria effectively.

Correct Answer: A

Rationale: In the evaluation phase of the nursing process, the nurse sets priorities for patient care to determine the effectiveness of nursing interventions. This involves comparing achieved outcomes with established goals. Choices B and D are related to evaluation as they involve determining whether outcomes or standards are met and documenting results of goal achievement, respectively. However, choice C, ambulating the patient, is an intervention that would typically occur in the implementation phase, not the evaluation phase. Therefore, the correct answer is A because setting priorities for patient care is a key component of the evaluation phase.

Correct Answer: C

Rationale: The correct answer is C because in the humoral immune response, B cells are stimulated by T helper cells or macrophages to differentiate into plasma cells that produce antibodies or memory cells. This process involves the production of specific antibodies that target the foreign antigen. Choice A is incorrect because B cells do not phagocytize antigens; instead, they produce antibodies. Choice B is incorrect because T cells do not turn into plasma cells. It is the B cells that differentiate into plasma cells in the humoral immune response. Choice D is incorrect because T cells do not produce antibodies. T cells are involved in cell-mediated immunity, not the humoral immune response.

Correct Answer: D

Rationale: Step 1: A goal should be measurable to track progress effectively. Step 2: The statement "a measurable change in a patient's physical state" indicates a specific and quantifiable outcome. Step 3: This aligns with the SMART criteria for goal setting - Specific, Measurable, Achievable, Relevant, Time-bound. Step 4: Other choices lack the specificity and measurability required for a clear goal. Step 5: Choice A talks about restriction, which is not directly related to understanding a goal. Step 6: Choice B focuses on negative responses, which is not necessarily indicative of understanding the goal. Step 7: Choice C is vague and lacks the specificity of a measurable outcome.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Dressing changes twice a day help maintain a clean wound environment, reducing the risk of infection. 2. Regular dressing changes promote proper wound healing by facilitating moisture balance and removal of dead tissue. 3. It is a direct intervention that addresses the patient's poor wound healing. 4. Teaching the patient about signs of infection (B) is important but does not directly address the wound healing process. 5. Instructing the family on dressing changes (C) is helpful but should not substitute direct patient care. 6. Refocusing the patient from body image changes (D) is not directly related to improving wound healing.