After receiving a dose of penicillin, a client develops dyspnea and hypotension. Nurse Celestina suspects the client is experiencing anaphylactic shock. What should the nurse do first?

Correct Answer: B

Rationale: The correct answer is B: Administer epinephrine, as prescribed, and prepare to intubate the client if necessary. In anaphylactic shock, immediate administration of epinephrine is crucial to reverse the severe allergic reaction. Intubation may be necessary to maintain airway patency in case of severe respiratory distress. Choice A is incorrect because paging an anesthesiologist and preparing for intubation should not be the first action; administering epinephrine takes precedence. Choice C is incorrect as administering an antidote for penicillin would not address the immediate life-threatening symptoms of anaphylactic shock. Choice D is incorrect as inserting a urinary catheter and infusing IV fluids are not the priority actions in managing anaphylactic shock.

Correct Answer: C

Rationale: Nurse Katrina would suspect organ rejection in Randy if she observes hypertension. Hypertension can indicate decreased kidney function due to rejection, leading to fluid retention and increased blood pressure. Sudden weight loss (A) is more likely due to other factors like poor appetite or stress. Polyuria (B) is excessive urination and not directly related to kidney rejection. Shock (D) is a severe and life-threatening condition that may occur in cases of severe rejection, but hypertension is a more common and early indicator.

Correct Answer: D

Rationale: The rule of nines is used to estimate the percentage of body surface area affected by burns. The upper trunk comprises 18% of the total body surface area, making it the largest single area. This is why choice D is the correct answer. The other choices are incorrect because the face and neck (choice A) represent 4.5%, the right upper arm and penis (choice B) represent 4.5%, and the right thigh and penis (choice C) represent 9%, which are all smaller percentages compared to the upper trunk.

Correct Answer: C

Rationale: The correct answer is C because in chronic renal failure (CRF), the kidneys are unable to effectively filter waste products from the blood, leading to elevated levels of blood urea nitrogen (BUN) and serum creatinine. BUN levels higher than 100 mg/dl and serum creatinine levels higher than 6.5 mg/dl indicate impaired kidney function, which is characteristic of CRF. A is incorrect because in CRF, pH tends to be decreased rather than increased due to metabolic acidosis. B is incorrect because in CRF, there is typically a buildup of potassium, magnesium, and calcium in the blood, not an increase in their serum levels. D is incorrect because uric acid levels and phenolsulfonphthalein excretion are not specific markers for CRF. Therefore, C is the correct answer based on the characteristic laboratory findings in chronic renal failure.

Correct Answer: A

Rationale: The correct answer is A: Turn him frequently. Turning the client frequently helps redistribute pressure, reducing the risk of pressure ulcers. This promotes circulation and relieves pressure on specific areas. Passive ROM exercises (B) are important for maintaining joint mobility but do not directly prevent pressure ulcers. Reducing fluid intake (C) is not recommended as hydration is crucial for skin health. Using a footboard (D) may help with positioning but is not as effective as regular turning for preventing pressure ulcers.