(A) A blood pressure within acceptable range best demonstrates compliance, but weight loss cannot be accomplished without adherence to medication, diet, and exercise. (B) Absence of side effects does not indicate compliance with medication. Pill counts can be misleading because the client can alter pill counts prior to visit. (C) Left ventricular hypertrophy is not an accurate measure of compliance because hypertrophy frequently does not decrease even with pharmacological management. (D) Therapeutic blood levels measure the drug level at the time of the test. There is no indication of compliance several days before testing.

Explanation
(A) Obtaining vital signs is important after connecting the client to the monitor because vital signs should be stable before the client is discharged from the emergency room. (B) All are important, but the first priority is to monitor the client's rhythm. (C) If the client is in severe pain, pain medication should be given after connecting him to the monitor and obtaining vital signs. (D) Completion of the history profile is the least important of the nursing actions.

Explanation/Reference:
Explanation:
(A) The infant has not ingested any protein immediately after birth, which is necessary to detect excessive serum phenylalanine. (B) It is important that the infant take in 2-3 full days of milk or formula feedings to preclude a false-negative reading. (C) At 2-3 days of age, inadequate milk could have been ingested owing to a delay in the initial feeding. (D) The biochemical buildup of serum phenylalanine is detectable after 2-3 days of milk or formula ingestion.

Section: Questions Set B
Explanation:
(A) Hand washing would be an important action designed to prevent transmission of pathogens from the hands to the eye. (B) Wearing sunglasses when going outside will prevent airborne pathogens from entering the eye.
(C) Eye patches are most frequently ordered to be worn while the client sleeps or naps, not constantly for this length of time. (D) Eye medications are sterile; clients need to be taught how to maintain this sterility.

(A)
The client could contract an infection, but at this point it is not the most pertinent issue.
(B)
The client's statement indicates that she does not grasp the full impact of her illness. Further client education must be given, along with allowing her to express her feelings regarding her illness. (C) The client may require a transfusion, but this is a temporary measure because the causative agent has not been identified. Her feelings regarding her illness must be addressed in order for care to continue. (D) A bone marrow is done first to make a definitive diagnosis; then treatment may begin.