The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action should the nurse take first?

Correct Answer: C

Rationale: The correct action is to medicate the patient with prescribed morphine first. The patient is experiencing incisional pain, poor cough effort, and coarse crackles, indicating possible atelectasis or pneumonia post-thoracotomy. Morphine will help relieve the pain, improve cough effort, and decrease anxiety associated with breathing difficulties. It is essential to address pain and discomfort to facilitate effective coughing and deep breathing exercises, promoting optimal lung expansion and preventing respiratory complications. Sitting upright, splinting the chest, or using the incentive spirometer are important interventions but addressing the pain is the priority in this situation.

Correct Answer: D

Rationale: Rationale: The correct answer is D. The BCG vaccine can cause a false-positive TB skin test result. Asking if the patient received the BCG vaccine is crucial to interpret the TB skin test accurately. If the patient received the BCG vaccine, the nurse should consider alternative diagnostic tests for TB. Incorrect choices: A: Asking about OTC medications is not directly related to the accuracy of the TB skin test. B: Family history of TB is important for assessing the patient's risk but does not impact the interpretation of the skin test. C: The duration of time since moving to the US may provide context but does not influence the TB skin test results.

Correct Answer: C

Rationale: The correct answer is C because it demonstrates therapeutic communication by encouraging the client to express their thoughts and feelings. This approach helps the nurse understand the underlying reasons for the client's behavior and can lead to addressing issues such as anxiety or depression. Option A is incorrect as it doesn't address the client's emotional needs. Option B is incorrect as prescribing medication should not be the first response to social withdrawal. Option D is incorrect as it overlooks the importance of exploring the client's emotional state. Overall, option C is the best choice as it promotes open communication and a holistic approach to addressing the client's concerns.

Correct Answer: A

Rationale: The correct answer is A: Instruct the client to limit protein intake. Limiting protein intake is unnecessary for blood pressure control. Here's the rationale: 1. Sodium intake: Excessive salt intake can lead to high blood pressure, so teaching the client to avoid adding salt to foods is important. 2. Weight management: Excess weight can contribute to high blood pressure, so discussing weight reduction or maintenance is crucial. 3. Exercise: Regular physical activity can help lower blood pressure, making it important to stress the importance of an exercise program. 4. Protein intake: While a balanced diet is important for overall health, limiting protein intake specifically is not typically a key factor in blood pressure control.

Correct Answer: B

Rationale: The correct answer is B: Fatigue, confusion, and weakness. Hypercalcemia is characterized by high levels of calcium in the blood, leading to neurological symptoms like fatigue, confusion, and weakness. This occurs due to the effect of excess calcium on the nervous system. Choices A, C, and D are incorrect as hypertension and bradycardia are not typical manifestations of hypercalcemia, laboratory results of potassium and sodium levels do not specifically indicate hypercalcemia, and decreased urine output is not a typical symptom of hypercalcemia.