Correct Answer: C

Rationale: The highest priority when caring for a patient with manifestations of appendicitis is to provide pain relief. By inserting a saline lock for intravenous pain medication, the patient can receive immediate pain relief to alleviate their discomfort. Pain management is crucial in appendicitis as it can help in improving the patient's overall well-being and reduce the risk of complications. While other options such as withholding food and fluids, performing preoperative skin preparation, or teaching postoperative exercises are important aspects of care, addressing the patient's pain is the top priority to ensure their comfort and well-being.

Correct Answer: B

Rationale: Option B, washing the lower extremities with mild soap, drying the legs, and applying a light moisturizer, indicates effective teaching for a client with peripheral vascular disease (PVD). Proper hygiene, including gentle washing with mild soap, thorough drying to prevent moisture-related skin breakdown, and moisturizing to prevent dry skin and promote circulation, are key components of self-care for individuals with PVD. Option A is incorrect because sitting with a pillow behind the knees does not specifically address PVD self-care. Option C is incorrect because crossing the left leg over the right while sitting does not relate to appropriate PVD management. Option D is incorrect because smoking in any form is detrimental to vascular health and should be discouraged in PVD management.

Correct Answer: C

Rationale: After an embolus becomes trapped in the pulmonary microvasculature, dead space increases. Dead space refers to the portion of the lung that is ventilated but not perfused, resulting in reduced gas exchange. When a pulmonary embolus blocks blood flow within a pulmonary vessel, it leads to a mismatch between ventilation and perfusion in the affected lung region. This mismatch results in increased dead space, as ventilation continues in areas that are not effectively perfused. As dead space increases, the overall efficiency of gas exchange in the lung is impaired, potentially leading to hypoxemia.

Correct Answer: D

Rationale: When performing medication teaching for the client's family about fibrinolytic therapy with alteplase (rt-PA), the nurse should include information that this medication is administered to break up existing clots and increase cerebral blood flow. rt-PA works by converting plasminogen to plasmin, which helps dissolve clots and restore blood flow to the brain. It is used specifically for ischemic strokes, not hemorrhagic strokes, and is most effective when administered within 3 hours (up to 4.5 hours in some cases) of the stroke symptoms starting. It is associated with potential serious complications, including an increased risk of bleeding, which the nurse should also educate the family about.

Correct Answer: B

Rationale: B. Recommendations for perineal cleansing: Proper perineal hygiene is important in preventing urinary tract infections (UTIs). Teaching the patient to cleanse the perineal area properly can help reduce the risk of UTIs.