Mr. RR is being prepared for surgery. Nursing care would include:

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Assessment of neurologic signs establishes baseline for post-op care. 2. Helps detect any changes post-surgery. 3. Enables prompt intervention if any issues arise. 4. Planning activities (B) is not a priority pre-surgery. 5. Enema (C) may not be necessary for all surgeries. 6. Explaining complications (D) is important but not a primary pre-op nursing care.

Correct Answer: A

Rationale: The correct answer is A: Basophils. Basophils are a type of white blood cell that release histamine during allergic reactions. They contain granules filled with histamine, which is released when they encounter an allergen. Monocytes, eosinophils, and neutrophils do not release histamine during allergic reactions. Monocytes are involved in immune response and inflammation, eosinophils are responsible for combating parasitic infections, and neutrophils are primarily involved in fighting bacterial infections.

Correct Answer: A

Rationale: The correct answer is A: The client’s breathing will become easier. Epinephrine is the first-line treatment for anaphylaxis as it helps to reverse the severe respiratory symptoms. By administering epinephrine, it causes bronchodilation, which helps improve breathing by opening up the airways. Choices B, C, and D are incorrect. B is incorrect because epinephrine typically causes an increase in blood pressure due to its vasoconstrictive effects. C is incorrect because angioedema is a potential side effect of anaphylaxis and would not be expected to increase after epinephrine administration. D is incorrect because epinephrine helps to improve alertness and consciousness by increasing blood flow to the brain.

Correct Answer: C

Rationale: The correct answer is C: 2 hours. Blood should be administered within 30 minutes to 4 hours after removal from the refrigerator to prevent bacterial growth and maintain its efficacy. Option C falls within this timeframe, ensuring safety and effectiveness. Option A (1 hour) is too short, while option B (4 hours) and option D (6 hours) exceed the recommended timeframe, increasing the risk of bacterial contamination and compromising the quality of the blood product.

Correct Answer: A

Rationale: The correct answer is A: Apply zinc oxide to the surrounding skin. This intervention helps create a protective barrier between the irritating drainage or wound compresses and the skin, thus preventing maceration. Zinc oxide has moisture-repelling properties that can help keep the skin dry and reduce the risk of maceration. Choice B (Using a binder) may not address the root cause of maceration and could potentially increase pressure on the wound site. Choice C (Supporting the arm and shoulder with pillows) may provide comfort but does not directly prevent maceration. Choice D (Instructing the client not to shave axillary hair) is unrelated to preventing maceration from irritating drainage or wound compresses.

Correct Answer: A

Rationale: The correct answer is A: Inform the physician immediately. This is because finding a lump in the breast could be a sign of breast cancer, and early detection is crucial for effective treatment. The nurse should advise the client to seek medical evaluation promptly for further assessment, such as a mammogram or biopsy. Choice B is incorrect because squeezing the nipple could potentially worsen the condition or spread cancerous cells if present. Choice C is incorrect as waiting until after the next menstrual period may delay necessary medical attention. Choice D is incorrect as using a heating pad could mask symptoms and delay proper diagnosis and treatment.

Correct Answer: C

Rationale: The correct answer is C: “I’ll take my medication in the morning, every morning.” This statement reflects understanding of the treatment regimen by indicating consistency in taking bumetanide for hypertension control. Taking the medication as prescribed is crucial for its effectiveness in managing blood pressure. Choice A is incorrect because sunbathing all day may not be advisable, especially if the patient is on medication. Choice B is incorrect as it implies no consideration for dietary restrictions that may be necessary with the medication. Choice D is incorrect as stopping medication once blood pressure decreases is not recommended and can lead to rebound hypertension.

Correct Answer: C

Rationale: The rule of nines is a method used to estimate the extent of burns on a patient's body. According to this rule, each major body part is assigned a percentage value that represents the total body surface area (TBSA). In this case, Mr. Kawasaki has second-degree burns on his right leg and arm (9% each) and left leg (9%) and third-degree burns on his left arm (9%). Adding these percentages together, we get a total of 36%, which corresponds to the extent of burn on Mr. Kawasaki's body. Choice A (18%) is incorrect because it only considers one arm and one leg, neglecting the other affected areas. Choice B (45%) is incorrect as it overestimates the extent of burns by including additional body parts not affected. Choice D (54%) is also incorrect as it includes more body parts than those actually burned. Therefore, the correct answer is C (36%) as it accurately reflects the distribution of burns based

Correct Answer: B

Rationale: The correct answer is B: Related to impaired balance. The rationale for this is that a client with a cerebellar brain tumor may experience impaired balance due to the cerebellum's role in coordinating voluntary movements and maintaining balance. Impaired balance increases the risk for falls and other injuries. Visual field deficits, difficulty swallowing, and psychomotor seizures are not directly related to the cerebellum's functions in balance and coordination. Therefore, these choices are incorrect for this specific nursing diagnosis.