After laminectomy with a spinal fusion to treat a herniated disc, a patient reports numbness and tingling of the right lower leg. The first action the nurse should take is to

Correct Answer: A

Rationale: The correct answer is A: report the patient’s complaint to the surgeon. The numbness and tingling in the right lower leg could indicate nerve damage post-laminectomy with spinal fusion. It is crucial to inform the surgeon immediately to evaluate and address the issue promptly. Checking the preoperative assessment data (B) may not provide immediate insight into the current issue. Checking vital signs for hemorrhage (C) is important but not the priority in this scenario. Turning the patient to the left (D) would not address the underlying cause and could potentially worsen the symptoms. Reporting to the surgeon ensures timely intervention and prevents further complications.

Correct Answer: D

Rationale: The correct answer is D. The presence of diffuse lesions and skin sloughing on the client's mucous membranes is the greatest immediate threat in toxic epidermal necrolysis (TEN). This condition results in severe skin detachment, leading to increased risk of infection, fluid loss, and electrolyte imbalances. Skin sloughing can also affect mucous membranes, increasing the risk of respiratory compromise, sepsis, and systemic infection. The other choices are not the greatest immediate threat in TEN. Bacterial cellulitis (choice A) is a potential complication but not the most immediate threat. Fluid and electrolyte imbalances (choice B) are significant but secondary to the skin sloughing. A cascading autoimmune response (choice C) can occur in TEN but is not the immediate threat compared to the risk of mucous membrane involvement and skin sloughing.

Correct Answer: C

Rationale: The correct answer is C: Pulling the client up in bed. This action involves the greatest risk of skin shearing because it creates friction and shear forces on the skin, especially when the client is moved against the surface of the bed. This can lead to skin breakdown and pressure ulcers. Rolling the client from supine to side-lying position (B) and helping the client ambulate after surgery (D) can cause shear forces but to a lesser extent compared to pulling the client up in bed. Inserting a peripheral intravenous catheter (A) does not involve significant shear forces on the skin.

Correct Answer: D

Rationale: The skin's role in homeostasis includes temperature control, making 'thermal regulation by skin blood flow dilation or constriction'. The hypothalamus signals skin vessels to vasoconstrict e.g., conserving heat in cold (temp up 1°C) or vasodilate e.g., shedding heat in warmth (temp down 2°C) per Baranoski and Ayello (2004). , 'synthesis of vitamin K,' is false; skin makes vitamin D via UV e.g., 10 minutes sun yields 1000 IU not K, which liver produces. , 'elimination of carbon dioxide,' is lungs' job e.g., 35-45 mmHg CO2 exhaled, not skin. , 'glucose regulation by Langerhans cells,' misattributes; pancreatic islets, not skin's Langerhans (immune cells), manage glucose e.g., insulin drops 100 mg/dL. Skin's sweat and blood flow e.g., dilating vessels in 90°F heat regulate temp, a nurse's focus in fever or hypothermia. Unlike lungs or pancreas, skin's thermal role is dynamic, immediate, and measurable, aligning with essentials in *Wound Care Essentials*, making the accurate function.

Correct Answer: A

Rationale: A nonblanchable red area on the malleolus is 'Stage 1' , per Potter's *Essentials*. Intact skin with persistent erythema e.g., no lightening after 10 seconds marks early injury, unlike 'Stage 2' , partial-thickness e.g., open blister. 'Stage 3' is full-thickness e.g., fat exposed, not here. 'Stage 4' shows bone e.g., deep loss, not redness. A nurse records e.g., Malleolus red, intact' Stage 1's 60% progression risk, per NPUAP, needing padding. Potter notes Stage 1 as first warning, distinct from Stage 2's dermal breach, a physiological assessment staple. is the correct, initial stage.