The nurse recognizes that the major early problem for Mr. Gabatan will be:

Correct Answer: A

Rationale: The correct answer is A: Bladder control. This is the major early problem for Mr. Gabatan because urinary retention is a common complication post-surgery, especially for older males like him. Bladder control is essential for preventing urinary tract infections and maintaining overall health. Quadriceps setting (B) and client education (C) are important but not as critical early on. Use of aids for ambulation (D) is important but not the major early problem compared to bladder control in this case.

Correct Answer: C

Rationale: The correct answer is C: Bleeding gums and dark tarry stools. Thrombocytes are platelets responsible for blood clotting. Medications that depress thrombocytes can lead to decreased clotting ability, resulting in bleeding tendencies. Bleeding gums and dark tarry stools are common signs of bleeding due to decreased platelet function. A: Sore throat and swollen glands are more indicative of a possible infection or inflammation, not related to thrombocyte depression. B: Pernicious anemia with weakness is associated with vitamin B12 deficiency, not directly related to thrombocyte depression. D: Thickening of blood and bruising are not typical signs of decreased platelet function, but rather may be indicative of other conditions like clotting disorders.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Asking if the patient feels the need to go to the bathroom helps assess urgency. 2. Urinary retention may lead to the inability to sense the urge to void. 3. This question directly addresses the issue of voiding, crucial in diagnosing urinary retention. Summary: B: Mobility is not directly related to urinary retention. C: Medication timing is important but not directly related to urinary retention. D: Safety rail inquiry is more related to fall prevention, not urinary retention.

Correct Answer: A

Rationale: The correct answer is A (5 to 10 mcg/ml) because this range is typically considered therapeutic for phenytoin (Dilantin) for seizure control. Levels below 5 mcg/ml may be subtherapeutic, leading to inadequate seizure control. Levels above 10 mcg/ml can increase the risk of toxicity. Choices B, C, and D are incorrect because they are outside the optimal therapeutic range, leading to either ineffective treatment (B, C) or an increased risk of adverse effects (D). Monitoring drug levels helps ensure the medication's effectiveness while minimizing side effects.

Correct Answer: A

Rationale: Step 1: Regular aerobic exercise helps lower blood pressure by improving heart health and circulation. Step 2: Exercise reduces stress and promotes weight loss, factors that contribute to hypertension control. Step 3: Alcohol consumption can raise blood pressure and should be limited or avoided. Step 4: Smoking and using low-tar cigarettes can still raise blood pressure and have other negative health effects. Step 5: Daily multivitamin supplements do not directly impact blood pressure control.

Correct Answer: C

Rationale: The correct answer is C because firm skin turgor indicates adequate hydration, a key goal of fluid resuscitation in diarrhea management. Firm skin turgor reflects the body's fluid balance and hydration status. When fluid resuscitation is successful, the patient's skin turgor improves due to replenished fluid levels. Choices A, B, and D are incorrect as they do not directly assess hydration status or the effectiveness of fluid resuscitation. Passing formed stools, decrease in stool frequency, and absence of perianal burning may be positive outcomes in diarrhea management, but they do not specifically indicate successful fluid resuscitation.

Correct Answer: C

Rationale: The correct answer is C because subjective data refers to information provided by the patient based on their feelings, perceptions, and experiences. In this case, the patient describing excitement about discharge is subjective data as it reflects the patient's emotional state. The other choices, A, B, and D, are considered objective data because they are observable and measurable by the nurse. The patient's temperature can be measured (A), the wound appearance can be visually assessed (B), and the patient pacing the floor is an observable behavior (D). Therefore, these choices are not subjective data.

Correct Answer: A

Rationale: The correct answer is A: Identify factors interfering with goal achievement. This is the priority action because it focuses on understanding what caused the patient to fall despite the goal of preventing falls. By identifying the factors interfering with goal achievement, the nurse can make necessary adjustments to the care plan to prevent future falls. Choice B is incorrect because counseling the nursing assistive personnel and removing the fall risk sign does not address the root cause of the fall. Choice C is incorrect because shifting responsibility to the charge nurse for documentation does not address the immediate need to assess and address the factors contributing to the fall. Choice D is incorrect because documenting the fall is important but not the priority when the immediate concern is understanding why the fall occurred.

Correct Answer: C

Rationale: The correct answer is C: Maintaining the integrity of the urinary system. This is crucial in preoperative preparation for a client with malignant tumors to prevent complications such as urinary obstruction or infection. Assessing symptoms of peritonitis (B) is important but not as critical as ensuring urinary system integrity. Insertion of an ostomy pouch (A) and nasogastric tube diversion procedure (D) may be necessary interventions for some cases, but they are not as essential as ensuring the urinary system's integrity to prevent serious complications.