Correct Answer: A

Rationale: The correct answer is A: Ensure client safety. This is the nurse's primary legal responsibility as it aligns with the ethical principle of beneficence, prioritizing the well-being and safety of the client. Ensuring client safety is essential to prevent harm and promote positive health outcomes. Following physician orders precisely (B) is important but not the primary legal responsibility of the nurse. Documenting care comprehensively (C) is crucial for accountability and continuity of care but is not the primary legal responsibility. Providing client-centered education (D) is essential for empowering clients but is not the primary legal responsibility in terms of legal accountability and duty of care.

Correct Answer: A

Rationale: The correct answer is A: The sympathetic nervous system saves fluid in response to the stress of surgery. The sympathetic nervous system is responsible for the "fight or flight" response, which includes the conservation of fluids during stressful situations. Dark amber and concentrated urine indicates dehydration, which can be a result of the sympathetic nervous system conserving fluids. B: The sympathetic nervous system does not "diereses" (increase urination) in response to stress. C: The parasympathetic nervous system is not involved in fluid conservation during stress. D: The parasympathetic nervous system does not "diereses" fluid in response to stress.

Correct Answer: D

Rationale: Autoimmunity is when the immune system mistakenly attacks the body's own cells. Choice D is correct because it reflects this key feature - the inability to differentiate self from nonself. This leads to the immune system targeting healthy tissues. Choices A, B, and C are incorrect as they do not accurately describe autoimmunity. Choice A refers to endotoxins destroying B cells, which is not the definition of autoimmunity. Choice B mentions overproduction of reagin antibody, which is not related to autoimmunity. Choice C is incorrect as autoimmunity does not involve depression of the immune response but rather an inappropriate immune response.

Correct Answer: D

Rationale: The correct answer is D: throbbing headache. Nitroglycerin is a vasodilator that relaxes blood vessels, leading to increased blood flow and reduced workload on the heart. One common side effect of nitroglycerin is a throbbing headache due to the dilation of blood vessels in the brain. This side effect is expected and usually diminishes with continued use. Explanation of other choices: A: High blood pressure - Nitroglycerin actually helps lower blood pressure by dilating blood vessels. B: GIT irritation - This is not a common side effect of nitroglycerin, as it primarily affects the cardiovascular system. C: Shortness of breathing - This is not a typical side effect of nitroglycerin, as it does not directly affect respiratory function.

Correct Answer: C

Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to collect objective data directly from the patient, which is crucial in establishing a comprehensive patient database. By assessing the patient's physical condition, the nurse can gather vital information such as vital signs, overall health status, and potential areas of concern. Reviewing literature (A) and checking orders for tests (B) may provide additional insights but are not direct data collection methods. Ordering medications (D) is a treatment intervention, not a data collection method.