A client is 2 days post operative. The vital signs are: BP - 120/70, HR - 110, RR - 26, and Temperature - 100.4 degrees Fahrenheit (38 degrees Celsius). The client suddenly becomes profoundly short of breath, skin color is gray. Which assessment would have alerted the nurse first to the client's change in condition?

Correct Answer: B

Rationale: The correct answer is B: Respiratory rate. A sudden change in the client's respiratory rate, especially if the client becomes profoundly short of breath, indicates a critical change in condition such as respiratory distress or failure. This is a priority assessment as it directly relates to the client's oxygenation and respiratory status. In this scenario, the client's increased respiratory rate of 26 breaths per minute, along with the symptoms of profound shortness of breath and gray skin color, indicates potential respiratory compromise. Monitoring the respiratory rate would have alerted the nurse first to the client's deteriorating condition. Summary of other choices: A: Heart rate - Although an elevated heart rate of 110 bpm is present, it is less indicative of respiratory distress compared to the respiratory rate in this situation. C: Blood pressure - The blood pressure of 120/70 is within normal range and may not be the first indicator of respiratory distress. D: Temperature - A temperature of 100.4 degrees Fahrenheit is slightly

Correct Answer: B

Rationale: The correct answer is B: The reservoir bag collapses during inspiration. This is important to report because it indicates inadequate oxygen delivery to the patient, potentially leading to hypoxemia. The reservoir bag should remain inflated to ensure a sufficient oxygen supply. A: Moisture accumulation inside the mask is common and not a cause for concern unless excessive. C: The mask covering the mouth and nose is expected and does not impact oxygen delivery. D: The strap being snug ensures a proper fit but does not directly impact oxygen delivery. In summary, choice B is the correct answer as it directly relates to the effectiveness of oxygen delivery, while the other choices are not as critical in this context.

Correct Answer: A

Rationale: The correct answer is A because losing a child is considered one of the most devastating experiences a person can face, regardless of the circumstances. The sudden death of a young person on the brink of adulthood adds layers of complexity and emotional pain. The loss of potential, unfulfilled dreams, and the traumatic nature of the accident all contribute to the intense grief and difficulty in coping. Choice B is incorrect because while the child may experience grief and confusion, the emotional impact is typically less compared to losing a child. Choice C is incorrect as the relationship with the alcoholic spouse may have been strained due to addiction, potentially lessening the emotional attachment. Choice D is incorrect as the grandparent may experience grief over the loss of their grandchild, but the intensity is generally lower than losing a child directly.

Correct Answer: C

Rationale: Correct Answer: C Rationale: 1. Heparin is administered subcutaneously, not intramuscularly, so aspirating is not necessary. 2. Aspirating can cause bruising or bleeding due to the fragility of subcutaneous blood vessels. 3. Massaging after the injection can lead to hematoma formation. 4. By not aspirating before or massaging after the injection, the risk of complications is minimized. Summary: A: Incorrect - Aspirating can lead to complications, and massaging may cause hematoma. B: Incorrect - Massaging for one minute is excessive and can increase the risk of hematoma formation. D: Incorrect - Massaging the site can lead to bruising, and aspiration is unnecessary and potentially harmful.

Correct Answer: C

Rationale: The correct answer is C because raising the fluid container 12-18 inches above the patient's anus ensures a slow, controlled flow of the enema solution into the rectum, allowing for proper cleansing without causing discomfort or injury. This height creates enough pressure to facilitate the flow but prevents excessive pressure that could lead to bowel perforation. Choice A is incorrect because cold water can cause discomfort and cramping, while warm water is recommended for its soothing effect. Choice B is incorrect as the rectal tube should be inserted 3-4 inches into the rectum to ensure proper administration. Choice D is incorrect as removing and reinserting the rectal tube multiple times can disrupt the flow and increase the risk of introducing air into the rectum.