Which organ is responsible for the extensive metabolism of acetaminophen?

Correct Answer: A

Rationale: The correct answer is A: Liver. The liver is responsible for the extensive metabolism of acetaminophen through various pathways, including glucuronidation, sulfation, and oxidation. It converts acetaminophen into less toxic metabolites for elimination. The kidneys (B) primarily filter blood and regulate fluid balance; the lungs (C) are involved in gas exchange; and the pancreas (D) produces digestive enzymes and insulin, not involved in acetaminophen metabolism. Therefore, the liver is the correct choice for this question.

Correct Answer: A

Rationale: The correct answer is A because it helps differentiate between orthopnea (difficulty breathing when lying down) and paroxysmal nocturnal dyspnea (sudden awakening due to difficulty breathing). By asking about worsening symptoms when lying down, the nurse can assess if the patient has orthopnea, a classic symptom of heart failure. Choices B, C, and D are incorrect because they do not specifically target the nighttime breathing difficulty associated with heart failure.

Correct Answer: D

Rationale: The correct answer is D: Diagnostic reasoning. When formulating diagnostic statements, nurses use diagnostic reasoning to analyze data, identify patterns, and make accurate clinical judgments. This process involves critical thinking and synthesizing information to reach a conclusion. Physical assessment skills (C) are important in data collection but not the primary focus in formulating diagnostic statements. Rationale (A) refers to providing reasons or justifications and is not directly related to the diagnostic process. American Nurses Association recommendations (B) may guide nursing practice but are not specifically used in formulating diagnostic statements.

Correct Answer: C

Rationale: The correct answer is C because validating the data by asking a colleague to listen to the breath sounds helps to ensure accuracy and reliability. It allows for a second opinion to confirm the nurse's assessment and prevents any potential misinterpretation. This collaborative approach promotes patient safety and quality care. Choices A and D are incorrect as they do not address the immediate need for validation and may delay appropriate intervention. Choice B is also incorrect as it does not ensure the accuracy of the assessment and may lead to miscommunication or incorrect treatment decisions.

Correct Answer: B

Rationale: The correct answer is B: Administer pain relief. The first priority for a client with an open wound is to manage their pain to ensure their comfort and well-being. Pain relief helps the client relax, reduces stress, and promotes healing. Cleaning and dressing the wound, administering anticoagulants, and monitoring blood pressure are important tasks but are secondary to addressing the client's immediate pain and discomfort. Pain relief should be the initial focus to ensure the client's overall care and recovery.

Correct Answer: A

Rationale: The correct answer is A: Turn the client every two hours. This action helps prevent pressure ulcers by relieving pressure on specific areas of the body. Turning the client redistributes pressure, promotes circulation, and reduces the risk of tissue damage. It is a crucial part of pressure ulcer prevention in immobile or bedridden patients. Increasing protein intake (B) may aid in wound healing but does not directly prevent pressure ulcers. Encouraging rest (C) may not address the root cause of pressure ulcers. Applying dressings to wounds (D) is a treatment for existing ulcers, not prevention.

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: A

Rationale: The correct answer is A: Administer epinephrine. Epinephrine is the first-line treatment for anaphylaxis, a severe allergic reaction. It works by constricting blood vessels, increasing heart rate, and opening airways, which can reverse the life-threatening effects of an allergic reaction. Antihistamines (B) may help with mild symptoms but are not sufficient for severe reactions. Corticosteroids (C) are used to reduce inflammation but work too slowly for immediate relief. Beta-blockers (D) can worsen allergic reactions by blocking the effects of epinephrine.

Correct Answer: A

Rationale: The correct answer is A because asking "Why haven't you taken your insulin?" may put the patient on the defensive. This question can come across as accusatory or judgmental, potentially making the patient feel guilty or defensive. It may hinder open communication and lead to a breakdown in the nurse-patient relationship. Explanation of other choices: B: While the question may be an attempt to gather information, it lacks sensitivity and may not promote open dialogue. C: Involving the patient's wife without the patient's consent may breach confidentiality and undermine the patient's autonomy. D: While asking the question may reveal reasons for the behavior, it is not the best approach as it can create a barrier to effective communication.