A client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. The nurse notes that the client's leg is pain-free, without redness or edema. The nurse's actions reflect which step of the nursing process?

Correct Answer: D

Rationale: The correct answer is D: Evaluation. In the nursing process, evaluation is the final step where the nurse determines if the goals and outcomes of care have been achieved. In this scenario, the nurse is assessing the client's condition before discharge to ensure there are no signs of thrombophlebitis. The absence of pain, redness, and edema indicates successful treatment. This step aligns with the evaluation phase as the nurse is assessing the client's response to treatment. A: Assessment is incorrect because the nurse has already assessed the client's leg and is now determining the effectiveness of the treatment. B: Analysis is incorrect as this step involves interpreting the data collected during assessment to identify problems and make nursing diagnoses. C: Implementation is incorrect as this step involves carrying out the nursing interventions to achieve the established goals. The nurse has already implemented the treatment plan in this scenario.

Correct Answer: C

Rationale: The correct answer is C: Retraction or dimpling. This finding is a deviation from normal as it can indicate possible breast cancer or other abnormalities. Retraction or dimpling can be a sign of tissue distortion or fibrosis, which should be further evaluated. Presence of striae (A) is common and not a cause for concern. Breasts that are rounded (B) and slightly unequal in size are considered normal variations. Simply being round (D) does not necessarily indicate a deviation from normal.

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.