The nurse is assessing a client who reports pain relief after taking an opioid analgesic. What would the nurse assess next?

Correct Answer: A

Rationale: The nurse would assess the level of sedation next, as opioids commonly cause drowsiness by depressing the central nervous systema key side effect impacting safety (e.g., falls) and dosing adjustments. Post-relief monitoring prioritizes this. Choice B, blood pressure, may drop with opioids, but sedation's immediacy and frequency make it more urgent to check. Choice C, appetite, isn't a primary concernnausea, not hunger, is more typical. Choice D, range of motion, improves with pain relief but isn't a side effect to assess; it's secondary. Choice A is correct, reflecting nursing vigilanceassessing sedation (e.g., drowsiness scale) ensures the opioid's benefit (pain relief) doesn't compromise safety, guiding interventions like timing or dose tweaks.

Correct Answer: D

Rationale: Heart sounds S1 and S2, known as 'lub' and 'dub,' have distinct characteristics based on their anatomical origins and auscultation points. S1, caused by the closure of the mitral and tricuspid valves, is loudest at the apex of the heart (near the left fifth intercostal space), where the mitral valve's sound is most prominent. S2, resulting from the closure of the aortic and pulmonic valves, is loudest at the base (second right and left intercostal spaces), where these valves are closest to the chest wall. Choice D correctly states this: 'S1 is loudest at the apex, and S2 is loudest at the base.' Choice A is incorrect because S1 and S2 do not sound equally loud across the entire cardiac area; their intensity varies by location. Choice B is wrong because S1 is actually louder, not fainter, at the apex, and Choice C is inaccurate since S2 is louder, not fainter, at the base. Understanding these auscultatory landmarks is crucial for accurate cardiac assessment, and Choice D reflects the physiological reality of heart sound distribution, making it the correct answer.

Correct Answer: B

Rationale: Implementation in the nursing process involves carrying out the care plan, and for drug therapy, this includes administering medications and documenting them (Choice B). Documentationrecording the drug, dose, time, route, and patient responseis a legal and clinical requirement ensuring accountability and continuity of care. Developing a content outline (Choice A) relates to teaching plans, not direct drug administration. Establishing outcome criteria (Choice C) and setting realistic goals (Choice D) occur during planning, not implementation, as they define what the therapy aims to achieve (e.g., pain reduced to 3/10'). For example, after giving morphine, the nurse documents it in the medication administration record and notes the patient's pain level, fulfilling implementation. This action supports safety (e.g., preventing double-dosing) and informs evaluation. While all steps are interconnected, only documenting drugs given directly ties to the act of implementing drug therapy, making Choice B the correct answer.

Correct Answer: D

Rationale: Postoperative care prioritizes the ABCsairway, breathing, circulationespecially after general anesthesia, which depresses the central nervous system, impairing gag and swallow reflexes. 'Risk for aspiration related to anesthesia' (Choice D) is the highest priority because residual anesthetic effects can allow gastric contents to enter the lungs, causing life-threatening aspiration pneumonia. Acute pain (Choice A) is significant but manageable with medication and doesn't immediately threaten survival. Deficient fluid volume (Choice B) from surgical losses is critical but secondary to airway patency, addressed via IV fluids. Impaired mobility (Choice C) is a longer-term concern, not urgent. For example, a groggy client with a weak cough risks silent aspiration, detectable only through vigilant monitoring (e.g., oxygen saturation, respiratory rate). Aspiration's rapid lethality (minutes) versus pain or fluid loss (hours) elevates Choice D as the correct, top-priority diagnosis.

Correct Answer: D

Rationale: Post-tonsillectomy, a lethargic client risks aspirating blood or secretions from the surgical site, as drowsiness impairs airway protection. Side-lying (Choice D) is most therapeutic because it promotes drainage from the mouth, reducing aspiration riskgravity keeps fluids from pooling in the throat. Semi-Fowler's (Choice A, 30-45°) and High-Fowler's (Choice C, 60-90°) elevate the head but keep the client upright, allowing secretions to trickle back toward the airway in a groggy state. Supine (Choice B) is worst, flattening the body and maximizing aspiration risk. For example, a client oozing blood from tonsillar beds, if supine, could inhale it, causing obstruction or pneumonia. Side-lying aligns with postoperative airway management principles, especially while consciousness returns slowly. Comfort for sore throat is secondary to safety, making Choice D the correct position.