Correct Answer: A

Rationale: The correct answer is A. Bedfast clients with increased serum BUN and creatinine levels are at high risk for overflow incontinence. This occurs due to decreased bladder function and reduced ability to sense bladder fullness, leading to the bladder overfilling and leaking urine.
Choice B describes symptoms related to possible urinary tract infections or renal issues, but these do not directly indicate overflow incontinence.
Choice C, a history of frequent urinary tract infections, may suggest other urinary issues but not specifically overflow incontinence.
Choice D, a confused client who forgets to go to the bathroom, is more indicative of functional incontinence rather than overflow incontinence.

Correct Answer: B

Rationale: The correct answer is B: 'Impaired skin integrity related to altered circulation and pressure.' This nursing diagnosis is the most appropriate as it directly addresses the Stage II pressure ulcer on the left hip, which is caused by altered circulation and pressure due to the client's left-side paralysis.
Choice A is incorrect because it focuses on the risk for impaired tissue integrity rather than the current issue of impaired skin integrity.
Choice C is incorrect as ineffective tissue perfusion is not the primary issue in this scenario.
Choice D is incorrect as it only addresses the left-side paralysis and not the pressure ulcer or altered circulation.

Correct Answer: D

Rationale: The correct answer is D because viral meningitis with a slight increase in temperature is less acute and complex compared to the other conditions. This change in temperature does not indicate a critical or urgent situation requiring immediate attention or intervention beyond the scope of a practical nurse.

Choices A, B, and C present more significant changes in health status such as a decrease in Glasgow Coma Scale score, an increase in intracranial pressure indicated by blood pressure changes, and a significant drop in blood pressure, respectively. These changes require closer monitoring and intervention by registered nurses due to the higher acuity and complexity of care needed for these conditions.

Correct Answer: D

Rationale:
Correct Answer: The best response for the nurse is to choose option D, 'I understand you are frustrated with the wait time.' This response demonstrates empathy and validates the client's feelings, helping to defuse the situation.
Choice A is not the best response as it does not directly address the client's emotions or concerns.
Choice B is inappropriate as it gives preferential treatment based on the client's behavior.
Choice C, while true, does not acknowledge the client's frustration or offer empathy.

Correct Answer: A

Rationale: The most important action for the nurse to take when the bubbling in the water-seal chamber of the right chest tube stops is to check the chest tube connections to the water-seal container. This is crucial to ensure there are no disconnections or leaks affecting the bubbling. Replacing the water-seal collection container (choice
B) is not necessary unless there is a malfunction; increasing suction (choice
C) without assessing the connections can be harmful, and 'milking' the tubing (choice
D) is an inappropriate action that can cause damage to the system.