Correct Answer: D

Rationale: The correct answer is D: Exhale deeply as the nurse re-inflates the cuff. Rationale: 1. When the cuff of the tracheostomy tube is deflated, the client should be instructed to exhale deeply to prevent aspiration of secretions. 2. Exhaling helps to clear the airway by pushing secretions out of the trachea, reducing the risk of aspiration. 3. Inhaling or holding the breath while the cuff is being re-inflated can increase the risk of inhaling secretions. 4. Coughing as the cuff is being deflated (choice A) may not be as effective in clearing secretions as exhaling deeply. 5. Taking a deep breath as the nurse deflates the cuff (choice C) may not be as effective as exhaling deeply in preventing aspiration. In summary, choice D is the correct answer because exhaling deeply helps clear secretions and reduce the risk of aspiration, while the other choices may

Correct Answer: A

Rationale: The correct answer is A because it demonstrates data validation in the nursing clinical decision-making process. The nurse assesses the time of the last dressing change and observes old and new drainage, which are relevant data points for wound care. This approach ensures that the decision to remove the dressing is based on accurate and validated information, leading to appropriate patient care. Choice B is incorrect because it relies on subjective information (increased pain and family request) rather than objective data validation. Choice C is incorrect as it involves a direct request for an order without sufficient data validation. Choice D is incorrect because elevating a leg cast based solely on a patient's report of decreased mobility does not involve thorough data validation related to the specific care needed for the patient's condition.

Correct Answer: C

Rationale: The correct answer is C: Autoantibodies. In Hashimoto's thyroiditis, the immune system mistakenly attacks the thyroid gland by producing autoantibodies against thyroid proteins such as thyroglobulin and thyroid peroxidase. These autoantibodies lead to inflammation and destruction of thyroid tissue. Antigen-antibody complexes (choice A) are not the main mechanism in Hashimoto's thyroiditis. Viral (choice B) and bacterial infections (choice D) do not directly cause autoimmune destruction of the thyroid in this condition. Autoantibodies targeting the thyroid gland are the key pathogenic factor in Hashimoto's thyroiditis.

Correct Answer: B

Rationale: Step 1: Keeping the neck in midline helps prevent compression of the lymphatic vessels in the neck, reducing the risk of impaired skin integrity in Hodgkin's disease. Step 2: This position also helps maintain proper blood flow and lymphatic drainage in the neck area. Step 3: Trimming nails short, using mild soap, and supporting bony prominences are not directly related to preventing impaired skin integrity in Hodgkin's disease. Summary: Choice B is correct as it directly addresses the specific risk factor of impaired skin integrity in Hodgkin's disease, while the other choices are not as relevant to this particular concern.

Correct Answer: D

Rationale: The correct answer is D: Dopar. Dopar is a drug that increases dopamine levels by converting into dopamine in the brain. This directly restores dopaminergic activities. Artane (A) is an anticholinergic used for Parkinson's symptoms, Elavil (B) is a tricyclic antidepressant, and Benadryl (C) is an antihistamine, none of which directly target dopaminergic activities like Dopar does.