A client has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first?

Correct Answer: D

Rationale: When a client with major fecal incontinence reports irritation in the perianal area, the nurse's initial action should be to assess the client's perineum to gather more information. By checking the perineum, the nurse can identify the extent and nature of the irritation, allowing for appropriate interventions to be initiated. This assessment is crucial in developing a comprehensive care plan and addressing the client's immediate needs effectively. Applying the nursing process priority-setting framework helps in planning care and prioritizing nursing actions, making assessment the initial step in this scenario. Applying a fecal collection system (choice A) would be premature without assessing the perineal area first. Similarly, applying a barrier cream (choice B) or cleansing and drying the area (choice C) should follow the assessment to ensure appropriate interventions are chosen based on the assessment findings.

Correct Answer: B

Rationale: The correct answer is B. Decreasing the intake of high-fat foods is essential in managing pancreatitis as high-fat foods can exacerbate symptoms and lead to complications. By reducing high-fat foods in their diet, the client demonstrates an understanding of the dietary management needed for pancreatitis. Choices A, C, and D are incorrect. Increasing high-fat foods (Choice A) is not recommended for pancreatitis as it can worsen the condition. While high-protein foods (Choice C) can be beneficial in some cases, the primary focus in pancreatitis management is on reducing fat intake. Decreasing high-protein foods (Choice D) is not a key dietary management approach for pancreatitis.

Correct Answer: C

Rationale: Submerging the chest tube end in sterile water creates a water seal, preventing pneumothorax if disconnected taping delays, clamping risks tension pneumothorax, and reinserting uncleaned spreads infection. Nurses act quickly, ensuring lung re-expansion, critical in chest tube care.

Correct Answer: B

Rationale: BP 60/40 (B) is highest priority; severe hypotension threatens perfusion, per ABCs (circulation). Pain (A), fever (C), and cyanosis (D) are urgent but secondary to life-threatening shock. B demands immediate action, making it correct.

Correct Answer: A

Rationale: Rotating the vial between hands mixes regular insulin gently, ensuring even suspension without denaturing it warming, shaking, or large needles risk potency loss or tissue damage. Nurses use this technique, confirming clarity, for safe, effective glycemic control in type 1 diabetes.

Correct Answer: A

Rationale: The correct answer is A. Increasing intake of foods high in vitamin D is beneficial for improving calcium absorption and managing osteoporosis. Vitamin D helps the body absorb calcium, which is essential for bone health and can aid in managing osteoporosis effectively. Choice B is incorrect because reducing calcium intake would be counterproductive for a client with osteoporosis, as calcium is crucial for bone strength. Choice C is incorrect as phosphorus, while important for bone health, does not directly impact osteoporosis management as much as vitamin D and calcium. Choice D is incorrect as potassium is not directly linked to osteoporosis management, and reducing its intake is not typically part of dietary recommendations for osteoporosis.

Correct Answer: D

Rationale: In a clinical scenario requiring immediate follow-up, nurses prioritize findings indicating potential deterioration or instability. Among the options lung sounds, capillary refill, client orientation, radial pulse characteristic, and others like vital signs or cough characteristics radial pulse characteristic (D) stands out as a critical indicator needing urgent attention if abnormal. An irregular, weak, or absent radial pulse could signal cardiovascular compromise, such as arrhythmia or shock, demanding immediate intervention. Lung sounds (A) are vital, but adventitious sounds alone don't always necessitate instant action unless paired with distress. Capillary refill (B) reflects perfusion, but a delay (e.g., >2 seconds) is concerning only in context. Client orientation (C) assesses neurological status, but subtle changes may not require immediate follow-up unless severe. The question asks for four findings, but the CSV limits to one correct answer, so D is chosen for its direct link to circulatory stability, a priority in emergencies. Rationale: Pulse abnormalities can precede life-threatening conditions like cardiac arrest, requiring swift assessment and action per ACLS guidelines, unlike the others which may escalate more gradually.

Correct Answer: A

Rationale: Repositioning an immobile patient primarily aims to prevent pressure ulcers by relieving pressure on skin over bony areas, like the sacrum or heels, and enhancing blood flow. Prolonged immobility risks tissue breakdown due to constant compression, making regular movement a cornerstone of preventive care in nursing. While shifting positions can secondarily support joint mobility, this isn't the main goal specific exercises target that more effectively. Building muscle strength requires active effort beyond repositioning, and though respiratory benefits may occur, they're addressed through targeted interventions like breathing exercises. This focus on skin integrity reflects nursing's priority to mitigate a common, severe complication of immobility, ensuring patient safety and comfort through proactive care.

Correct Answer: A

Rationale: The correct answer is A: 'I should avoid foods that contain lactose.' Lactose intolerance results from the inability to digest lactose, a sugar found in dairy products. Avoiding foods that contain lactose is essential in managing symptoms like bloating, diarrhea, and abdominal pain. Choice B is incorrect because increasing dairy intake would worsen symptoms. Choice C is incorrect because gluten is unrelated to lactose intolerance. Choice D is incorrect because high-fiber foods are beneficial for other conditions but do not specifically address lactose intolerance.