Correct Answer: B

Rationale: The correct answer is B: "I will press the button whenever I feel pain." This answer demonstrates understanding of how patient-controlled analgesia (PCA) works, where the client self-administers medication when needed for pain relief. Option A is incorrect as the machine is programmed with lockout intervals to prevent overdosing. Option C is incorrect as the client should only press the button when experiencing pain, not on a fixed schedule. Option D is incorrect as PCA does not guarantee complete pain elimination. The key in PCA is empowering the client to self-administer medication based on their pain level.

Correct Answer: C

Rationale: During the evaluation phase, the nurse performs the key action of determining the effectiveness of the care plan. This involves assessing whether the client's goals are being met, if interventions are achieving the desired outcomes, and if any modifications are necessary. This step is crucial to ensure the care plan is successful and the client's needs are being addressed appropriately. Choice A is incorrect because diagnosing the client's condition is typically done in the assessment phase, not during evaluation. Choice B is incorrect as identifying nursing interventions is part of the planning phase. Choice D is incorrect as developing goals and outcomes is part of the planning phase as well. Overall, the evaluation phase focuses on assessing the effectiveness of the care plan rather than diagnosing, identifying interventions, or developing goals.

Correct Answer: D

Rationale: The correct answer is D: Lymphocyte. Lymphocytes are a type of white blood cell that play a crucial role in adaptive immunity. They include T cells and B cells, which are responsible for recognizing and attacking specific pathogens. T cells help regulate the immune response and directly attack infected cells, while B cells produce antibodies to target pathogens. Neutrophils (A), monocytes (B), and basophils (C) are important for innate immunity, not adaptive immunity. Neutrophils are phagocytic cells that engulf and destroy pathogens, monocytes differentiate into macrophages to engulf pathogens, and basophils are involved in allergic reactions. Therefore, the correct answer is D because lymphocytes are key players in adaptive immunity.

Correct Answer: B

Rationale: The correct answer is B: Ask the patient to describe the type of reaction. This is the first action the nurse should take because it helps determine the severity of the allergy and how to best proceed with care. By understanding the specific type of reaction the patient experiences, the nurse can implement appropriate precautions and interventions to prevent any adverse reactions during the patient's stay. Choice A is incorrect because placing the patient in isolation is not necessary for a latex allergy. Choice C is incorrect as terminating the interview is premature and does not address the patient's allergy. Choice D is also incorrect as documenting the allergy is important but not the first action to take when assessing a patient's allergic reaction.

Correct Answer: A

Rationale: The correct answer is A: Hypocortisolism. After a transsphenoidal hypophysectomy, the pituitary gland is removed or partially removed, leading to decreased cortisol production. Signs of hypocortisolism include weakness, fatigue, hypotension, weight loss, and electrolyte imbalances. Hyperglycemia (B) is not typically associated with this procedure. Hypoglycemia (C) is not a common concern post-hypophysectomy. Hypercalcemia (D) is not directly related to pituitary gland removal. Therefore, assessing for hypocortisolism is crucial for early detection and management post-surgery.