Correct Answer: D

Rationale: In end-stage liver disease, pruritus (itching) can be a distressing symptom caused by the accumulation of bile salts in the skin due to impaired liver function. Cholestyramine and other bile acid sequestrants are the primary treatment for managing pruritus in these patients. These medications bind to the bile salts in the intestine, preventing their reabsorption and reducing the itching symptoms. Antihistamines may not be as effective for this type of pruritus since it is not histamine-mediated. Topical corticosteroids are generally not recommended for long-term use in liver disease due to the risk of systemic absorption and adverse effects. Avoiding hot showers or baths may provide some temporary relief but is not a definitive treatment. Therefore, prioritizing the prescription of cholestyramine or bile acid sequestrants would be the most appropriate intervention to address the severe pruritus in a patient with end-stage liver disease

Correct Answer: B

Rationale: The presentation of a patient with diabetes mellitus showing symptoms of polyuria, polydipsia, nocturia, and fatigue along with laboratory findings of hyperglycemia, glycosuria, and ketonuria is indicative of diabetic ketoacidosis (DKA). DKA is a serious complication of diabetes characterized by hyperglycemia, metabolic acidosis, and ketosis. The increased glucose levels lead to glycosuria, causing osmotic diuresis resulting in polyuria, polydipsia, and nocturia. The body starts breaking down fats for energy in the absence of sufficient insulin, leading to the production of ketones causing ketonuria. The patient may also experience fatigue due to the metabolic abnormalities present in DKA.

Correct Answer: C

Rationale: Persistent, severe abdominal pain, tenderness, and rigidity in a postpartum client can be indicative of serious conditions such as uterine rupture, hemorrhage, or infection, which require urgent medical attention. As a nurse, the priority action in this situation is to notify the healthcare provider immediately so that appropriate interventions can be initiated promptly to ensure the safety and well-being of the client. Administering analgesics or providing emotional support may not address the underlying cause of the symptoms and could potentially delay necessary medical treatment. Assisting the client to a comfortable position can be considered once the healthcare provider has been informed and appropriate assessments and interventions have been initiated.

Correct Answer: D

Rationale: When performing an intramuscular (IM) injection, the nurse should insert the needle at a 90-degree angle into the muscle. This angle helps ensure proper and deep penetration into the muscle tissue for effective administration of the medication. It also helps prevent leakage or tissue damage at the injection site. Additionally, inserting the needle at a 90-degree angle facilitates accurate delivery of the medication into the muscle where it can be absorbed properly. Therefore, selecting the correct angle for inserting the needle is critical in ensuring the success and effectiveness of the IM injection.

Correct Answer: B

Rationale: Religious Affiliation is not typically included in the history taking process for diagnosing medical conditions. While a patient's religious beliefs may sometimes be relevant in certain situations, it is not a standard component of medical history. History taking usually includes aspects such as the history of present illness, social and family history, and past medical history as these can provide important information related to the patient's health condition.