Correct Answer: C

Rationale: The correct answer is C: Persistent cough. Enalapril is known to cause a persistent dry cough as a side effect. This adverse reaction is due to the accumulation of bradykinin in the lungs, leading to irritation and cough. The nurse should report this symptom to the provider for further evaluation and possible medication adjustment. Choices A, B, and D are not directly associated with enalapril use. While a blood pressure of 150/80 mm Hg is elevated and should be monitored, it is not a direct side effect of enalapril. Swelling in the legs and a heart rate of 72 beats per minute are also not typically related to enalapril use and should be assessed but are not the priority findings to report in this scenario.

Correct Answer: A

Rationale: The signs and symptoms of hyperkalemia include muscle weakness and cardiac arrhythmias, making choice A correct. Hyperkalemia can lead to dangerous cardiac effects, and calcium gluconate is used to stabilize the heart by antagonizing the effects of potassium. Choices B, C, and D describe symptoms and interventions that are not typically associated with hyperkalemia. Confusion and bradycardia are not common in hyperkalemia, and insulin and glucose are used in hyperkalemia only under specific circumstances. Fatigue and irregular heart rate are vague symptoms, and diuretics are not the primary treatment for hyperkalemia. Nausea and vomiting are nonspecific symptoms and sodium bicarbonate is not indicated for the management of hyperkalemia.

Correct Answer: B

Rationale: The correct answer is to wear gloves when applying the transdermal nicotine patch to prevent the nurse from absorbing nicotine through the skin. Choice A is incorrect because shaving hairy areas of skin is not necessary for applying a transdermal patch. Choice C is incorrect as transdermal patches should be applied immediately after removal from the protective pouch, not necessarily within 1 hour. Choice D is incorrect because the previous patch should be disposed of properly following institutional guidelines, not placed in a tissue.

Correct Answer: A

Rationale: The correct answer is A: Decerebrate posturing. Decerebrate posturing is an abnormal body posture characterized by rigid extension of the arms and legs, which indicates severe brainstem injury affecting the midbrain and pons. This posture suggests dysfunction or damage to neural pathways controlling muscle tone. Choice B, hypervigilance, is not typically associated with brainstem injury but rather with increased alertness and arousal. Choice C, absence of deep tendon reflexes, is not a specific finding related to brainstem injury. Choice D, a Glasgow Coma Scale score of 15, indicates a fully awake and alert state, which is not expected in a client with a brainstem injury.

Correct Answer: A

Rationale: The correct intervention for a patient experiencing hypovolemic shock is to administer IV fluids. In hypovolemic shock, there is a significant loss of circulating blood volume leading to inadequate perfusion to tissues. Administering IV fluids is crucial to restore blood volume and improve tissue perfusion. Monitoring blood pressure (choice B) is important but not the primary intervention in hypovolemic shock. Placing the patient in Trendelenburg position (choice C) can worsen outcomes by increasing intracranial pressure and is no longer recommended. Administering oxygen (choice D) is beneficial for many conditions but does not address the underlying issue of inadequate circulating blood volume in hypovolemic shock.