A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The nurse obtains a health history, measures vital signs, and auscultates for bowel sounds. Which step of the nursing process is the nurse performing?

Correct Answer: B

Rationale: The correct answer is B: Assessment. In this scenario, the nurse is collecting data by obtaining the health history, measuring vital signs, and auscultating for bowel sounds. Assessment is the first step in the nursing process, where data is gathered to identify the client's health status. Planning (A) involves setting goals and outcomes, Evaluation (C) involves determining the effectiveness of interventions, and Implementation (D) involves carrying out the planned interventions. In this case, the nurse is still in the data collection phase, making Assessment the correct choice.

Correct Answer: C

Rationale: Rationale: Choice C is correct because a pulse oximeter measures oxygen saturation in arterial blood, providing crucial information on the client's oxygen levels. This helps monitor respiratory status and determine the need for supplemental oxygen. Choice A is incorrect as tissue perfusion is not directly assessed by a pulse oximeter. Choice B is incorrect as it measures hemoglobin indirectly. Choice D is incorrect as anti-hypertensive medications do not impact oxygen saturation directly.

Correct Answer: B

Rationale: The correct answer is B because the toddler with severe deep abrasions over 98% of the body would be categorized as "treat last" in triage. This decision is based on the principle of prioritizing care based on the severity of injuries. Severe deep abrasions over a large body surface area indicate a critical condition that requires immediate medical attention to prevent complications like infection or shock. The other choices do not present as immediate life-threatening conditions as the severe abrasions, hence they would not be categorized as "treat last." The infant with bulging anterior fontanel may have a concerning sign, but it does not indicate an immediate life-threatening condition. The preschooler with leg fractures and school-age child with singed hair also do not present as critical as the toddler with severe abrasions.

Correct Answer: A

Rationale: The correct answer is A: Provide the client with generous fluid intake. Adequate fluid intake helps in thinning respiratory secretions, making it easier to obtain a sputum specimen. This measure promotes hydration, which can facilitate coughing and sputum production. Regular position changes (B) may help prevent complications like pressure ulcers but are not directly related to obtaining a sputum specimen. A high-protein diet (C) and sufficient rest periods (D) are important for overall client well-being but do not specifically aid in obtaining a sputum specimen.

Correct Answer: B

Rationale: The correct answer is B: Ask the patient to sign a consent form for the procedure. This step is crucial to ensure that the patient understands the risks and benefits of the thoracentesis procedure and gives informed consent. Signing a consent form also protects both the patient and the healthcare provider legally. A: Reminding the patient to eat or drink nothing for six hours before the procedure is not necessary for a thoracentesis, as it is not typically a procedure that requires fasting. C: Positioning the patient on the side of the bed leaning over the bedside table is not correct for a thoracentesis procedure. The patient should be sitting upright or slightly leaning forward to facilitate the procedure. D: Pulling the privacy curtain and dimming the lights of the room are not essential steps for preparing a patient for a thoracentesis. These actions are more related to creating a comfortable and private environment but are not directly related to the procedure itself.