Correct Answer: D

Rationale: The correct answer is to measure the ulcer's depth and diameter. This intervention is crucial as it helps monitor healing progress and evaluate the effectiveness of the care plan. Measuring the ulcer provides valuable information about the wound's improvement or deterioration. Repositioning the client every 2 hours (Choice A) is important for preventing further skin breakdown but may not be the priority in this case. Cleansing the ulcer with normal saline (Choice B) is essential for wound care but not the most crucial intervention at this stage. Applying a moisture-retentive dressing (Choice C) can promote healing, but assessing the ulcer's dimensions is more critical for monitoring progress.

Correct Answer: C

Rationale: Increased blood pressure is the desired effect of administering dopamine (Intropin) to treat hypotension. Dopamine acts by stimulating adrenergic receptors, leading to vasoconstriction and increased cardiac output. This results in an elevation of blood pressure. Choices A, B, and D are incorrect as they do not directly reflect the therapeutic action of dopamine in treating hypotension. Increased heart rate may indicate the body compensating for low blood pressure, increased urinary output is more related to kidney function, and increased respiratory rate is often seen in response to respiratory issues, not the action of dopamine on hypotension.

Correct Answer: B

Rationale: The correct nursing diagnosis for this client is 'Impaired skin integrity related to altered circulation and pressure.' The client's Stage II pressure ulcer on the left hip is a clear indication of impaired skin integrity resulting from altered circulation and pressure due to immobility. Choice A is incorrect because the client already has a pressure ulcer, indicating an actual impairment rather than a risk. Choice C is incorrect as ineffective tissue perfusion is not the primary issue in this case. Choice D is incorrect as it focuses solely on the paralysis and not the actual skin integrity issue.

Correct Answer: A

Rationale: When a client is receiving opioids like morphine sulfate via a PCA pump, the most critical action for the nurse to implement is to monitor the client's respiratory status. Opioids can cause respiratory depression, which can be life-threatening. Monitoring respiratory status allows for early detection of any signs of respiratory compromise. Teaching the client how to use the PCA pump, evaluating pain level, and assessing pain level are important aspects of care but ensuring the client's safety by monitoring respiratory status takes precedence due to the potential risks associated with opioid administration.

Correct Answer: D

Rationale: The correct answer is D, 'Measure all emesis accurately.' When a client with a small bowel obstruction is experiencing frequent vomiting, measuring emesis accurately is crucial for monitoring fluid balance and preventing dehydration. Choice A, 'Maintain a quiet environment,' while important for patient comfort, is not as critical as accurately measuring emesis. Choices B and C, 'Ensure the linens are clean and dry' and 'Place an air deodorizer in the room,' focus on environmental factors that, although helpful, are not as essential as monitoring the client's fluid balance in this situation.