Correct Answer: A

Rationale: Pressure injuries on the heels are a concern as they can develop quickly and lead to serious complications, especially in surgical patients who are immobile for extended periods. Applying pressure-relieving devices, such as heel protectors or foam dressings, can help alleviate the pressure on the affected areas and prevent further damage. These devices are designed to distribute pressure evenly and reduce the risk of pressure injuries. It is important for the nurse to address the issue promptly to prevent additional harm to the patient's skin integrity.

Correct Answer: D

Rationale: A delimitation in a research study refers to setting specific boundaries or restrictions on the scope of the study. In this scenario, Gloria's decision to include only nurses with a minimum of three years experience as psychiatric nurses is a delimitation because it sets a specific criterion or boundary for the selection of participants. This helps to focus the study on a particular group of individuals who possess the required experience, ensuring the research is targeted and relevant to the topic being investigated.

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: A

Rationale: Shoulder dystocia is an obstetric emergency where one of the baby's shoulders becomes impacted behind the mother's pubic bone after the head delivers. This can lead to compression of the umbilical cord and compromise fetal oxygenation. The most critical nursing intervention in managing shoulder dystocia is applying suprapubic pressure to dislodge the impacted shoulder and allow for delivery of the baby. By gently pushing downwards on the mother's abdomen just above the pubic bone, the shoulder can be released, and the baby can be delivered successfully. This intervention should be prioritized to prevent potential complications for both the mother and the baby. Episiotomy may be considered if necessary, but it is secondary to addressing the shoulder dystocia. Oropharyngeal airway insertion and administering magnesium sulfate are not indicated in the immediate management of shoulder dystocia.

Correct Answer: A

Rationale: The described presentation is classic for acute angle-closure glaucoma. This condition is characterized by sudden-onset severe eye pain, headache, nausea, and vomiting. The red eye, steamy cornea (corneal edema), and mid-dilated non-reactive pupil are consistent with acute angle-closure glaucoma. The sudden increase in intraocular pressure leads to impaired aqueous humor outflow, causing these symptoms. Immediate intervention is required to prevent permanent vision loss in such cases. Central retinal artery occlusion would present with sudden painless vision loss. Optic neuritis typically presents with vision loss and pain with eye movements. Corneal ulcer presents with eye discomfort, foreign body sensation, and may have a history of corneal trauma or contact lens wear.