Correct Answer: B

Rationale:
Choice B is the correct answer because it addresses the client's concern by explaining that the shot will help relieve the pain in his feet, which is a symptom of peripheral neuritis. This response shows empathy and provides the client with a clear benefit of receiving the medication.

Choices A, C, and D do not directly address the client's immediate concern about the injection and its purpose, making them less suitable responses.
Choice A focuses on the client's behavior rather than the therapeutic effect of the injection.
Choice C shifts the responsibility to the client to administer the shot, which may not be appropriate in this situation.
Choice D mentions feeling calmer and less jittery, which is not directly related to the client's current complaint of pain in the feet.

Correct Answer: B

Rationale: Using sterile gloves to insert the catheter is crucial to maintaining sterile technique. Sterile gloves help prevent the introduction of microorganisms during the insertion process. Applying sterile gloves before cleansing the perineal area (
Choice
A) is important but not specific to maintaining sterility during catheter insertion. Cleaning the urinary meatus with an antiseptic solution (
Choice
C) is a step in the catheterization process but does not solely ensure sterile technique. Placing the drainage bag above the level of the bladder (
Choice
D) is incorrect; the bag should be placed below the level of the bladder to facilitate urine drainage.

Correct Answer: C

Rationale: The correct action for the nurse to take first is to assess the client's oxygen saturation level. In a client with COPD and abnormal respiratory and heart rates, determining the oxygen saturation helps evaluate the adequacy of oxygen exchange and the severity of respiratory distress. Administering a bronchodilator (choice
A) can be appropriate but assessing oxygen saturation takes priority. Encouraging deep breathing and coughing (choice
B) may not address the immediate need for oxygenation assessment. Obtaining an arterial blood gas (choice
D) is important but typically follows the initial assessment of oxygen saturation.

Correct Answer: D

Rationale: Successful extubation relies on the patient's ability to maintain an effective breathing pattern. This indicates that the patient can adequately oxygenate and ventilate without the need for mechanical support. Monitoring tissue perfusion, preventing infection, and ensuring safety are important but not directly related to the immediate criteria for successful extubation. Tissue perfusion, injury prevention, and infection control are crucial aspects of overall patient care but are not the primary factors to consider when evaluating readiness for extubation.

Correct Answer: C

Rationale: The correct answer is C: Rationalization. Rationalization is a defense mechanism where the client justifies their stress and need for perfection by creating logical explanations or excuses. In this case, the client is rationalizing their stress by believing that everything in their life must be perfect. Repression (choice
A) involves unconsciously blocking out thoughts or feelings. Sublimation (choice
B) is redirecting unacceptable impulses into socially acceptable activities. Displacement (choice
D) involves transferring emotions from one target to another.