Correct Answer: B

Rationale: Postoperative priorities follow the ABCs (Airway, Breathing, Circulation). Dark red drainage of 20 mL over 4 hours suggests potential bleeding, a circulation issue that could indicate hemorrhage a life-threatening complication after bowel resection. Pain of 6/10 is expected post-surgery and manageable with analgesics, not immediately urgent. Easy arousal with sleepiness reflects sedation or fatigue, not an acute threat unless airway compromise emerges. Urine output of 60 mL over 4 hours (15 mL/hr) is below normal (30 mL/hr), signaling oliguria, but bleeding takes precedence as it's more immediately lethal. Excessive drainage could destabilize the client faster than oliguria or pain, requiring urgent provider notification to assess for internal bleeding or anastomosis leakage. This aligns with postoperative monitoring protocols, emphasizing early detection of hemorrhage, making it the top priority to report.

Correct Answer: A, D

Rationale: Compartment syndrome requires relieving pressure to restore perfusion. Opening the splint (or cast) reduces external compression, an anticipated step pre-fasciotomy if tightness contributes to ischemia, per orthopedic protocols. Urinalysis checks for myoglobinuria from muscle breakdown, a diagnostic aid, but not immediate relief. NPO status prepares for surgery, a later consideration after pressure relief. A dependent leg position increases venous pooling, worsening swelling and pressure contraindicated here. Opening the splint directly addresses the mechanical cause, buying time for surgical evaluation, aligning with emergency management (e.g., AAOS guidelines), making it the expected prescription to prioritize limb viability.

Correct Answer: A

Rationale: A surgical mask during transport prevents droplet spread of influenza. An N95 and negative airflow are for airborne diseases, and immunization isn't given during active infection.

Correct Answer: A

Rationale: The client's generalized weakness, fatigue, shortness of breath, and pale mucous membranes (Exhibit 1) with a vegan diet suggest anemia, likely iron deficiency. Reinforcing education about nutritional supplements (e.g., iron, B₁₂) addresses potential deficiencies vegans risk low iron and B₁₂ without fortified foods while collecting intake data identifies dietary gaps, guiding tailored therapy. Increasing fluids and monitoring respiration might help hydration or respiratory distress, but anemia is the primary issue, not fluid status. Checking blood pressure (132/60 to 102/50 mm Hg) shows orthostasis, a symptom, not the cause oxygen isn't indicated with 94% saturation. Assessing fatigue is ongoing, but a chest X-ray targets lungs, not anemia. Education and data collection tackle the root nutritional cause, aligning with holistic care and prevention, making it the nurse's first action.

Correct Answer: A

Rationale: Dry mouth is a common side effect of clonidine; diarrhea and hypopigmentation aren't typical.