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

Correct Answer: B

Rationale: The nurse would assess gastrointestinal discomfort next, as NSAIDs (e.g., ibuprofen) commonly cause stomach irritation or ulcers by inhibiting prostaglandins that protect the gastric lininga frequent side effect needing monitoring post-relief. Choice A, respiratory rate, is key with opioids, not NSAIDs, which rarely affect breathing. Choice C, level of sedation, suits CNS depressants (e.g., narcotics), not NSAIDs, which don't typically drowsy. Choice D, blood pressure, may shift slightly with NSAIDs (e.g., fluid retention), but GI issues are more immediate and common. Choice B is correct, reflecting nursing vigilanceassessing for nausea, pain, or bleeding ensures NSAID benefits (pain relief) don't mask GI risks, prompting interventions like food intake or antacids to protect the stomach.

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.

Correct Answer: A

Rationale: During NREM sleep, especially stages 3-4 (deep sleep) at 4 a.m., the body enters a restorative state with parasympathetic dominance, lowering metabolic demand. 'Decreased TPR and BP' reflects this: total peripheral resistance (TPR) and blood pressure (BP) drop as heart rate slows (e.g., from 70 to 50 bpm) and vessels dilate, per circadian dips and sleep physiology. 'Increased TPR and BP' occurs in REM or stress, not NREM's calm. 'No change from daytime readings' ignores sleep's autonomic shift; daytime wakefulness elevates vitals (e.g., BP 120/80 vs. 100/60 at night). 'Highly individualized, cannot predict' overstates variability; while baselines differ, NREM consistently reduces vitals across healthy adults. For example, a nurse might record BP dropping 10-20% from daytime, aligning with Taylor's description of NREM's energy conservation. Choice A is the expected, evidence-based finding.