Correct Answer: C

Rationale: In a client diagnosed with a pulmonary embolism experiencing a reduction in arterial oxygen saturation level and dyspnea, the priority nursing diagnosis would be Impaired Gas Exchange. This is because a pulmonary embolism can obstruct blood flow and prevent proper gas exchange in the lungs. Dyspnea and reduced oxygen saturation levels indicate inadequate gas exchange, which can lead to hypoxia. Prioritizing this nursing diagnosis will ensure that interventions are focused on improving oxygenation and respiratory function to prevent further complications.

Correct Answer: A

Rationale: When auscultating the apical pulse in pediatric clients, the nurse should place the stethoscope at the fifth intercostal space at the midclavicular line. This location is where the apex of the heart is located in pediatric clients and provides the most accurate assessment of the apical pulse. Placing the stethoscope at the left nipple (B) or right nipple (C) would not provide an accurate assessment of the apical pulse location. Auscultating at the eighth intercostal space (D) would be too low and not capture the apical pulse accurately.

Correct Answer: B

Rationale: B. Coach in nonpharmacologic pain management techniques: The client's vital signs indicate they may be experiencing pain as evidenced by an elevated heart rate (P 119), which can be addressed initially with nonpharmacologic pain management techniques. This approach can help reduce pain and anxiety without the immediate need for medication.

Correct Answer: D

Rationale: Hemophilia is a genetic disorder that impairs the blood's ability to clot properly, leading to prolonged bleeding. This makes individuals with hemophilia particularly susceptible to hemorrhagic shock, which is a type of distributive shock. Distributive shock occurs when there is widespread vasodilation and increased vascular permeability, leading to inadequate tissue perfusion and oxygen delivery. In the case of hemophilia, excessive bleeding can result in a significant loss of blood volume and impaired circulation, eventually leading to distributive shock due to the body's inability to maintain adequate perfusion to vital organs. Therefore, individuals with hemophilia are at an increased risk of developing distributive shock, specifically hemorrhagic shock, if they experience severe bleeding events.

Correct Answer: C

Rationale: In a client diagnosed with a pulmonary embolism experiencing a reduction in arterial oxygen saturation level and dyspnea, the priority nursing diagnosis would be Impaired Gas Exchange. This is because a pulmonary embolism can obstruct blood flow and prevent proper gas exchange in the lungs. Dyspnea and reduced oxygen saturation levels indicate inadequate gas exchange, which can lead to hypoxia. Prioritizing this nursing diagnosis will ensure that interventions are focused on improving oxygenation and respiratory function to prevent further complications.