A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers?

Correct Answer: A

Rationale: The correct answer is A: A 79 year-old malnourished client on bed rest. This client is at highest risk for decubitus ulcers due to malnourishment causing poor tissue healing, and immobility leading to pressure ulcers. The other choices are less likely: B may have increased pressure but obesity does not directly correlate with ulcer risk, C's incontinence may increase risk of skin breakdown but not as high as malnutrition and immobility, and D's ambulatory status reduces the risk compared to bed rest.

Correct Answer: B

Rationale: The correct answer is B, lower abdomen. Securing the catheter tubing in the lower abdomen helps prevent dislodgment by reducing movement and tension on the catheter. This area allows for easy monitoring of the catheter site and minimizes the risk of accidental removal. Taping the catheter tubing on the inner thigh or lower thigh may lead to increased friction and movement, increasing the risk of dislodgment. Choosing "All of these" is incorrect because taping the catheter tubing in multiple areas can cause unnecessary discomfort and potential complications for the client.

Correct Answer: C

Rationale: The correct answer is C: Droplet isolation precaution. This is because droplet precautions are used to prevent the spread of infectious agents that are transmitted through respiratory droplets. In this scenario, the client must wear a surgical mask when outside the room to prevent the spread of droplets containing pathogens to others. A: Airborne precautions are used for pathogens that can be transmitted through the air over long distances, such as tuberculosis. B: Contact precautions are used for direct contact with the client or their environment to prevent the spread of pathogens. D: Standard precautions are used for all clients to prevent the spread of infection through contact with blood, body fluids, or contaminated surfaces.

Correct Answer: C

Rationale: The correct answer is C: Sitting position. Placing the client in a sitting position during an abdominal paracentesis allows for easier access to the abdomen and minimizes the risk of complications such as lightheadedness or hypotension. This position also promotes optimal drainage of ascitic fluid. A: Supine position is not ideal as it may not provide optimal access to the abdomen for the procedure. B: Left lateral position with legs flexed may not be appropriate as it can hinder access to the abdomen and fluid drainage. D: Right side-lying position is not recommended as it may obstruct access to the abdomen and make the procedure more challenging.

Correct Answer: D

Rationale: The correct answer is D: Auscultate the chest for change or clearing in adventitious breath sounds. This method is the best way to evaluate the effectiveness of tracheal suctioning because it directly assesses the patient's respiratory status. By auscultating the chest, the nurse can listen for any changes in breath sounds, such as clearing of adventitious sounds, indicating improved airway clearance. This objective assessment provides concrete evidence of the intervention's impact on the patient's respiratory function. Incorrect answers: A: Note subjective data such as "My breathing is much improved now." Subjective data rely on the patient's perception and may not always accurately reflect the actual physiological changes. C: Note objective findings such as decreased respiratory rate and pulse. While these are important vital signs, they may not directly indicate the effectiveness of tracheal suctioning in clearing the airway. B: This statement reflects subjective data and does not provide a direct assessment of the patient's respiratory status post-tracheal