Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. Bronchodilators help to relax and open up the airways, which can alleviate shortness of breath and chest tightness in conditions like asthma or COPD. Administering oxygen (choice B) can help if the client is hypoxic, but it does not directly address the underlying airway constriction. Applying a cold compress (choice C) may provide some comfort but will not address the respiratory distress. Administering IV antibiotics (choice D) is not indicated for shortness of breath and chest tightness unless there is an underlying bacterial infection.

Correct Answer: C

Rationale: Rationale: C: Reinforce the dressing is the correct intervention for serosanguineous drainage after cholecystectomy. This helps maintain a clean and dry wound environment, promotes healing, and prevents infection. Changing the dressing (B) may disrupt the wound healing process. Notifying the physician (A) is important but not the immediate intervention. Applying an abdominal binder (D) is not indicated for managing serosanguineous drainage.

Correct Answer: D

Rationale: The correct answer is D because the patient demonstrates orientation to person (knows their name), place (knows they are at the hospital in Victoria), and time (knows it is February of a new year – 2009). This indicates intact orientation across all three domains. Choice A is incorrect as the patient is unsure of their location and the year. Choice B is incorrect as the patient is confused about the date. Choice C is incorrect as the patient is uncertain about the date and only guesses their location.

Correct Answer: A

Rationale: The correct answer is A because asking the patient to rate pain intensity using a scale (like 0-10) provides a standardized measure of pain perception. This quantitative data helps healthcare providers assess pain severity accurately and track changes over time. Asking about allergies (B) is important but not directly related to pain assessment. Asking the patient to describe the pain (C) provides qualitative information but may not be as reliable or consistent as a numerical rating. Measuring pain intensity using a scale (D) is similar to the correct answer but does not involve the patient's subjective input, which is crucial in pain assessment.

Correct Answer: C

Rationale: The correct answer is C: Jaundice. In chronic liver disease, the liver's ability to process bilirubin is impaired, leading to jaundice. This is characterized by a yellowing of the skin and eyes. Monitoring for jaundice is crucial as it indicates liver dysfunction. Hypoglycemia (A) is not a typical complication of chronic liver disease. Hyperkalemia (B) is more commonly associated with kidney dysfunction. Anemia (D) can occur in liver disease but is not as specific a complication as jaundice. Therefore, monitoring for jaundice in a patient with chronic liver disease is essential for early detection and management of liver dysfunction.