Correct Answer: A

Rationale: The correct answer is A: Risk for impaired skin integrity. This is the highest priority as patients with spinal cord injuries are at high risk for pressure ulcers due to immobility. Preventing skin breakdown is crucial to avoid complications. Choices B, C, and D are not as urgent. Choice B may be a concern but preventing skin breakdown takes precedence. Choices C and D are important but not life-threatening like potential skin issues in this patient population.

Correct Answer: C

Rationale: The correct answer is C: Eating. Chewing food can trigger trigeminal nerve pain due to the movement and pressure applied on the nerve. The other choices (A: Sleeping, B: Reading, D: Cooking) do not involve the same level of jaw movement and pressure on the trigeminal nerve, thus are less likely to aggravate the pain. Therefore, eating is the most likely action to worsen trigeminal neuralgia symptoms in this scenario.

Correct Answer: C

Rationale: The correct answer is C: 5% dextrose and water with 60 mEq. This solution is appropriate because it provides both fluid replacement (water) and electrolyte replacement (60 mEq). The dextrose helps prevent hypoglycemia. Choice A is incorrect as 10% dextrose and saline may worsen hemoconcentration. Choice B is not ideal as 5% dextrose and water lacks electrolytes needed for fluid balance. Choice D, distilled water with KCl, is dangerous as it lacks dextrose and may lead to electrolyte imbalances.

Correct Answer: B

Rationale: The correct answer is B: Encourage ambulation and liberal fluid. Encouraging ambulation can help in the movement of kidney stones and alleviate pain. Liberal fluid intake helps in flushing out kidney stones and preventing further stone formation. Incorrect options: A: Administering prescribed nephrotoxic drugs can worsen kidney function and exacerbate the pain. C: Observing aseptic principles when changing intake is important for infection prevention but not directly related to pain management for renal calculi. D: Providing a comfortable position can offer temporary relief but does not address the underlying cause of kidney stone pain.

Correct Answer: A

Rationale: The correct answer is A because gathering and organizing needed supplies is a crucial step before performing a complex dressing change. By ensuring all necessary supplies are readily available, the nurse can streamline the process, minimize interruptions, and promote efficiency. This step also helps maintain aseptic technique and prevent the spread of infection. Deciding on goals and outcomes (B) is important but typically done as part of the care planning process, not immediately before a dressing change. Assessing the patient's readiness (C) is also important but can be done concurrently with gathering supplies. Calling for assistance (D) may be necessary in some situations, but it is not the immediate step required just before changing the dressing.