Correct Answer: A

Rationale: The correct answer is A: Avoiding using soap on the irradiated areas. Soap can irritate the skin and exacerbate the risk for impaired skin integrity in a client receiving radiation therapy. By avoiding soap, we minimize the risk of skin breakdown and promote skin healing. B: Applying talcum powder can actually worsen skin irritation and should be avoided. C: Wearing a lead apron is not relevant to the nursing diagnosis of risk for impaired skin integrity. D: Removing thoracic skin markings is not necessary for skin integrity and may disrupt the treatment plan.

Correct Answer: C

Rationale: The correct answer is C: Asymmetry. The ABCD method is a mnemonic used for assessing skin lesions for possible skin cancer. The A in ABCD stands for Asymmetry, indicating that the lesion is not symmetrical in shape or color. Skin cancers often exhibit asymmetrical features. Actinic (Choice A) refers to sun damage, Arcus (Choice B) is a term related to the eye, and Assessment (Choice D) is a general term that does not specifically relate to skin lesion evaluation. By focusing on asymmetry, healthcare providers can identify potential skin cancer lesions early for further evaluation and treatment.

Correct Answer: C

Rationale: The correct answer is C: Abdominal girth. Serum albumin helps to increase oncotic pressure in the blood vessels, reducing fluid leakage into the abdomen and decreasing ascites, leading to a decrease in abdominal girth. Option A is incorrect because serum albumin does not directly affect urinary output. Option B is incorrect as serum albumin does not directly impact serum ammonia levels. Option D is incorrect because while serum albumin can help improve liver function, it does not directly treat hepatic encephalopathy.

Correct Answer: A

Rationale: The correct answer is A: Deficient fluid volume related to osmotic diuresis. With a serum glucose level of 618mg/dl, the client is likely experiencing diabetic ketoacidosis, leading to excessive urination (osmotic diuresis) and dehydration. The priority is to address fluid volume deficit to prevent hypovolemic shock. The other options are not the priority because: B: Decreased cardiac output is a result of the increased heart rate, not the primary issue. C: Imbalanced nutrition is important but not as urgent as fluid volume deficit. D: Ineffective thermoregulation is a concern but not the priority in this scenario.

Correct Answer: B

Rationale: The correct answer is B: "I will press the button whenever I feel pain." This answer demonstrates understanding of how patient-controlled analgesia (PCA) works, where the client self-administers medication when needed for pain relief. Option A is incorrect as the machine is programmed with lockout intervals to prevent overdosing. Option C is incorrect as the client should only press the button when experiencing pain, not on a fixed schedule. Option D is incorrect as PCA does not guarantee complete pain elimination. The key in PCA is empowering the client to self-administer medication based on their pain level.