A nurse assesses an area of pale white skin over a patient's coccyx. After turning the patient on her side, the skin becomes red and feels warm. What should the nurse do about these assessments?

Correct Answer: B

Rationale: Recognize that this is ischemia, followed by reactive hyperemia' fits. Pale e.g., <15 mmHg then red/warm e.g., blood rush is normal e.g., 5 min unlike 'report ulcer' , premature e.g., no break. 'Document ulcer' and 'interventions' overreact e.g., not yet. A nurse observes e.g., Temp flush' per circulation shift, a physiological sign. The text defines this, making the correct, accurate response.

Correct Answer: B

Rationale: Correct Answer: B - Assess after removing the hose. Rationale: The nurse should assess the skin after removing the TED hose to thoroughly examine for any signs of skin irritation, pressure injury, or discoloration. Assessing over the hose (A) may not provide a complete view of the skin condition. Rolling down the hose (C) or rolling up the hose (D) can cause friction and compromise the integrity of the skin, making it an incorrect method for assessment.

Correct Answer: D

Rationale: The correct answer is D because MRSA is a highly contagious bacterium that can be transmitted through contact with infected wounds or secretions. Gloves are necessary to protect against direct contact, a gown adds an extra layer of protection for clothing contamination, goggles protect the eyes from splashes, and a face mask prevents inhalation of MRSA particles. Using only gloves (A) is insufficient protection. Adding a gown (B) is better but does not protect the face and eyes. Adding goggles (C) provides protection for the eyes but not the face. The most comprehensive protection is achieved with gloves, gown, goggles, and a face mask (D).

Correct Answer: A

Rationale: The correct answer is A: Isolate the client using transmission-based precautions. This is incorrect because bowel and bladder dysfunction does not typically require isolation measures unless there is a specific infectious disease present. B: Monitoring intake and output is important to assess kidney function and fluid balance in clients with bowel and bladder dysfunction. C: Providing hygienic care after episodes of incontinence helps prevent skin breakdown and infections. D: Using standard precautions when handling linen after episodes of incontinence is necessary to prevent the spread of infections to healthcare workers and other clients.

Correct Answer: D

Rationale: The correct answer is D: Administration of antibiotics to the client during labor. This is because giving antibiotics to the mother during labor can significantly reduce the risk of transmitting Group B streptococcus to the neonate during delivery. The antibiotics help to eradicate the bacteria in the birth canal, thus decreasing the chances of the baby becoming infected during birth. Not breastfeeding the neonate during the first week after birth (choice A) is not the correct intervention as breastfeeding is still recommended even if the mother is positive for Group B streptococcus. Administration of antibiotics to the neonate after birth (choice B) is not the first-line intervention as preventing transmission during labor is more effective than treating the neonate after birth. Delivery by cesarean section (choice C) is not the preferred intervention unless there are other obstetric indications for a cesarean section. Administering antibiotics to the client during labor (choice D) is the most appropriate intervention to prevent transmission of infection to the