Correct Answer: B

Rationale: A lactating woman (B) has the greatest need for additional protein intake. Lactation increases the metabolic demands for protein to support milk production, making it essential for the mother to have a higher protein intake. While clients in choices A, C, and D also require protein for various reasons, they do not have the same increased protein demands as a lactating woman.

Correct Answer: B

Rationale: To calculate the infusion rate, set up a ratio proportion problem: 50 ml/20 min = x ml/60 min. Cross multiply to solve: 50 60 / 20 = 150 ml/hr. Therefore, the infusion pump should be set to deliver the secondary infusion at a rate of 150 ml/hr.

Correct Answer: B

Rationale: During digital removal of a fecal impaction, a vagal response can occur due to stimulation of the anal sphincter. If the client experiences bradycardia (pulse rate decreases), the nurse should stop the procedure immediately and take corrective action to prevent any complications.

Correct Answer: A

Rationale: Epigastric pain that radiates to the back (A) is the hallmark assessment finding of acute pancreatitis. The pancreas lies retroperitoneally in the upper abdomen, so inflammation often causes severe epigastric pain that radiates through to the back. Abdominal pain with guarding (B), nausea and vomiting (C), and increased bowel sounds (D) can also be present in acute pancreatitis but are less specific and may be seen in various other gastrointestinal conditions.

Correct Answer: A

Rationale: Before initiating a new medication, the nurse should conduct a thorough assessment of the client to identify any pre-existing health conditions or risk factors that could be affected by the medication. This assessment helps in establishing a baseline for monitoring potential side effects and determining the medication's appropriateness for the client.