Choice A reason: Tapping the wrists performs Tinel’s sign, a diagnostic test for carpal tunnel syndrome. Tingling or pain in the median nerve distribution (thumb, index, middle fingers) indicates nerve compression, common in repetitive computer use. This directly assesses the condition, identifying nerve irritation, making it the most specific action.

Choice B reason: Comparing capillary refill assesses vascular perfusion, not nerve compression. Carpal tunnel syndrome involves median nerve entrapment, causing pain and paresthesia, not circulatory issues. Capillary refill is normal in this condition, making this action irrelevant for diagnosing the client’s hand pain and numbness.

Choice C reason: Determining sleeping position may identify symptom triggers, like wrist flexion, but is not a diagnostic test. Carpal tunnel syndrome requires physical assessment, like Tinel’s sign, to confirm median nerve compression. Sleeping position is secondary, providing context but not direct evidence of the condition.

Choice D reason: Applying pressure over the ulnar artery assesses circulation, not median nerve compression. Carpal tunnel syndrome affects the median nerve, causing pain and tingling, not ulnar nerve or vascular issues. This action is irrelevant, as it does not evaluate the neurological symptoms described by the client.

Choice A reason: Amylase is elevated in acute pancreatitis due to pancreatic acinar cell damage, releasing digestive enzymes. Monitoring serum amylase confirms the diagnosis and tracks disease severity, as levels correlate with inflammation. This is a key marker, essential for assessing pancreatic injury in sudden abdominal pain.

Choice B reason: Glucose levels rise in pancreatitis due to impaired insulin release from damaged pancreatic beta cells. Hyperglycemia indicates disease severity and complications like pancreatic necrosis. Monitoring glucose ensures timely management of metabolic disturbances, critical in acute pancreatitis with sudden pain and systemic effects.

Choice C reason: Serum triglycerides are monitored, as hypertriglyceridemia is a common cause of acute pancreatitis. Elevated levels exacerbate pancreatic inflammation by inducing lipotoxicity. Tracking triglycerides guides treatment, like lipid-lowering therapy, and assesses risk of recurrent attacks, making it essential in suspected pancreatitis cases.

Choice D reason: Calcium levels drop in acute pancreatitis due to fat necrosis binding calcium (saponification). Hypocalcemia signals severe disease and complications like tetany. Monitoring calcium ensures timely supplementation, preventing life-threatening outcomes, and is critical for managing systemic effects in acute pancreatic inflammation.

Choice E reason: White blood cell count rises in pancreatitis due to systemic inflammatory response. Leukocytosis indicates infection or severe inflammation, guiding antibiotic or supportive care needs. Monitoring this assesses disease progression and complications, making it vital for managing suspected acute pancreatitis with abdominal pain.

Choice A reason: Platelets are unaffected by hydrocortisone in Addison’s disease. Hydrocortisone replaces cortisol, regulating metabolism, not coagulation. Platelet monitoring is relevant for bleeding disorders, not adrenal insufficiency, making this value less critical than glucose, which is directly impacted by cortisol’s gluconeogenic effects.

Choice B reason: Albumin reflects nutritional status but is not directly altered by hydrocortisone. Addison’s disease and hydrocortisone affect glucose and electrolytes via cortisol’s metabolic roles, not protein synthesis. Albumin is secondary, as glucose monitoring addresses immediate metabolic complications of corticosteroid therapy.

Choice C reason: Glucose is critical to monitor, as hydrocortisone increases gluconeogenesis and insulin resistance in Addison’s disease, risking hyperglycemia. Elevated glucose can cause osmotic diuresis or ketoacidosis, requiring dose adjustments or insulin therapy, making this the most important value to ensure safe corticosteroid management.

Choice D reason: Serum electrolytes, like sodium and potassium, are affected by Addison’s, but hydrocortisone primarily corrects hyponatremia and hyperkalemia. Glucose is more critical, as hydrocortisone’s glucocorticoid effects directly raise blood sugar, posing immediate metabolic risks, making this value secondary to glucose monitoring.

Choice A reason: Severe headache with photosensitivity suggests meningitis or dehydration but is less urgent than rebound tenderness, which indicates peritonitis. In acute abdominal pain, neurological symptoms are secondary to potential surgical emergencies like appendicitis, requiring immediate reporting for possible operative intervention.

Choice B reason: Right lower abdomen rebound tenderness indicates peritoneal irritation, likely appendicitis, in acute abdominal pain. This surgical emergency risks rupture, causing peritonitis or sepsis, necessitating immediate reporting to the provider for urgent imaging or surgery, making it the priority finding over other symptoms.

Choice C reason: Petechial hemorrhage under the eyes suggests coagulopathy or increased intracranial pressure but is less specific to acute abdominal pain. Rebound tenderness directly indicates a surgical emergency like appendicitis, making petechiae a secondary concern requiring evaluation after addressing peritoneal signs.

Choice D reason: Dark green emesis indicates bile or obstruction but is less urgent than rebound tenderness, which signals peritonitis. Vomiting is managed with fluids, but tenderness suggests a surgical condition like appendicitis, requiring immediate reporting to prevent complications like perforation.

Choice A reason: Measuring intake and output monitors fluid balance but does not address blood clots obstructing TURP drainage. Clots risk bladder distension or hemorrhage, and increasing irrigation flow directly clears the tubing, making this action secondary to preventing immediate complications in post-prostate surgery.

Choice B reason: Increasing bladder irrigation flow is the best initial action, as blood clots in TURP drainage indicate clot formation, risking obstruction. Faster irrigation flushes clots, preventing bladder distension or bleeding, maintaining catheter patency, and ensuring postoperative stability, making it the priority intervention.

Choice C reason: Providing oral fluids increases urine output but does not directly clear blood clots in TURP drainage. Clots require irrigation adjustment to prevent obstruction, and oral hydration is secondary, as it does not address the immediate risk of catheter blockage or bladder complications.

Choice D reason: Administering an antispasmodic addresses bladder spasms but not blood clots in TURP drainage. Clots cause obstruction, not spasms, and increasing irrigation flow directly resolves the issue, making antispasmodics irrelevant for the immediate problem of maintaining catheter patency.

Choice A reason: Determining the quickest onset is important but secondary to matching pain severity with dosing. Pain scale rating guides appropriate medication selection, as prescriptions are dosed for specific pain levels, ensuring effective relief without overuse, making this action less critical initially.

Choice B reason: Asking the client to choose medication is inappropriate, as patients lack expertise to select based on pharmacology. Pain scale rating informs the nurse’s decision, aligning with prescribed doses, ensuring safe and effective analgesia, making this action incorrect for professional nursing practice.

Choice C reason: Documenting pain is necessary but not the first action. Comparing pain scale rating with dosing ensures appropriate medication selection, addressing pain effectively before recording. Documentation follows intervention, making this action secondary to selecting the correct analgesic based on severity.

Choice D reason: Comparing pain scale rating with prescribed dosing is critical, as PRN analgesics are dosed for specific pain levels (e.g., mild vs. severe). This ensures the nurse selects the appropriate medication, optimizing pain relief while minimizing overdose risk, making it the priority action before administration.

Choice A reason: Discussing medications with the provider is necessary but vague and not actionable during the call. Bringing medication containers provides concrete data, ensuring accurate preoperative reconciliation, reducing risks like drug interactions, making this response less effective for immediate medication assessment.

Choice B reason: Bringing prescription records is helpful but less direct than medication containers, which show current drugs, doses, and adherence. Records may be incomplete, and containers allow visual verification, ensuring accurate perioperative planning, making this response secondary to physical medication review.

Choice C reason: Bringing medication containers is the best response, as it allows the nurse to verify all current medications, doses, and schedules. This ensures accurate preoperative reconciliation, preventing drug interactions or withdrawal, critical for safe anesthesia and surgery, making it the priority instruction.

Choice D reason: Obtaining records from the provider is time-consuming and may delay preoperative planning. Medication containers provide immediate, accurate data for reconciliation, reducing risks of errors, making this response less practical than having the client bring physical containers for direct review.

Choice A reason: A purple stoma mucosa indicates ischemia or necrosis, a surgical emergency post-colostomy. Poor blood supply risks stoma failure, infection, or perforation, requiring immediate surgical evaluation. This finding is critical, as it threatens the colostomy’s viability, making it the priority to report.

Choice B reason: Brown, solid fecal matter is normal 24 hours post-colostomy, indicating bowel function. This does not suggest complications like ischemia or obstruction, requiring no immediate reporting, as it aligns with expected postoperative outcomes, making this finding benign.

Choice C reason: Streaks of bright red blood from the stoma suggest minor trauma or irritation, common post-colostomy. This is less urgent than purple mucosa, which indicates ischemia, a life-threatening issue, making bleeding a secondary concern requiring monitoring but not immediate surgical intervention.

Choice D reason: Absent bowel sounds in the left lower quadrant are expected post-bowel surgery due to ileus. This is less urgent than purple stoma mucosa, which signals necrosis, requiring immediate action, making bowel sounds a normal postoperative finding not warranting urgent reporting.

Choice A reason: Educating on narcotic dependency is inappropriate during severe pain (8/10). Stage IV bone cancer requires aggressive pain control, and dependency concerns are secondary. Administering medications relieves suffering, aligning with palliative goals, making education irrelevant at this acute pain crisis moment.

Choice B reason: Waiting for a pain score of 10 delays relief, worsening suffering in stage IV bone cancer. Severe pain (8/10) requires immediate intervention with opioid and non-opioid drugs, as delaying treatment exacerbates distress, making this approach ineffective and contrary to pain management protocols.

Choice C reason: Administering opioid and non-opioid medications simultaneously is optimal, as opioids target nociceptive pain, and non-opioids (e.g., NSAIDs) reduce bone inflammation in stage IV cancer. This multimodal approach maximizes relief for severe pain (8/10), aligning with palliative care guidelines, making it the priority intervention.

Choice D reason: Alternating IV and IM analgesics is inefficient and delays relief. Simultaneous opioid and non-opioid use addresses severe pain (8/10) more effectively, targeting different pain pathways, reducing opioid needs, and improving outcomes, making alternating routes less effective for immediate control.

Choice A reason: Inspecting peripheral vein distention assesses superficial thrombosis, not deep vein thrombosis (DVT), which occurs in deep veins like the femoral. DVT presents with calf inflammation, not visible vein distention, making this assessment less specific for diagnosing the condition’s classic signs.

Choice B reason: Observing breathing pattern changes detects pulmonary embolism, a DVT complication, not DVT itself. Calf inflammation is a primary DVT sign, and breathing changes are secondary, making this assessment irrelevant for initial DVT evaluation, focusing on systemic rather than localized findings.

Choice C reason: Palpating pedal pulses assesses arterial flow, not venous thrombosis. DVT causes calf inflammation and swelling, not pulse changes, unless severe. This assessment is less relevant, as DVT primarily affects venous return, making calf inflammation the priority for diagnosis.

Choice D reason: Assessing calf inflammation is critical, as DVT causes unilateral swelling, redness, and warmth due to venous obstruction. This classic sign, often with pain, directly indicates thrombus formation, making it the most specific assessment for diagnosing DVT and guiding anticoagulation therapy.