Correct Answer: B

Rationale: The correct action for the nurse to take first when a client with a nasogastric tube reports feeling nauseated is to check the client's bowel sounds. This assessment helps the nurse evaluate for possible complications, such as a blockage or decreased gastric motility, that could be causing the nausea. Administering an antiemetic (Choice A) should not be the first action without assessing the underlying cause of the nausea. Slowing the rate of the feeding (Choice C) may be appropriate but is not the priority until further assessment is done. Placing the client in a supine position (Choice D) is not typically indicated for managing nausea in this situation.

Correct Answer: A

Rationale: The correct answer is A: 'If I eat 500 fewer calories per day, I should lose 1 pound per week.' This statement is accurate because a reduction of 500 calories per day typically results in a weight loss of 1 pound per week. This is based on the principle that a calorie deficit of 3,500 calories equals about 1 pound of body fat. Choices B, C, and D are incorrect because they do not align with the established relationship between calorie reduction and weight loss. Eating 450 fewer calories per day would not lead to a weight loss of 2 pounds per week; similarly, reducing calories by 250 or 300 per day would not result in losing 2 pounds or 1 pound per week, respectively.

Correct Answer: B

Rationale: Asking the client what the voices are saying is the priority action as it helps assess the content of the hallucinations. This assessment is crucial to determine if the client is at risk of harm to themselves or others. Encouraging the client to listen to music or providing a distraction may not address the underlying issues related to the hallucinations. Administering antipsychotic medication, although important, should come after a thorough assessment of the hallucinations to ensure the right medication and dosage are provided.

Correct Answer: D

Rationale: The correct answer is D. Swelling in the feet can indicate worsening heart failure due to fluid retention, and clients should report this to their healthcare provider immediately. Choices A, B, and C are incorrect because weighing once a week may not provide timely information on fluid retention, timing of diuretic medication is usually advised in the morning to prevent nocturia, and limiting fluid intake to 3 liters per day may not be appropriate for all clients with heart failure.

Correct Answer: A

Rationale: Performing chest compressions during cardiac resuscitation is a critical life-saving intervention that can be delegated to an assistive personnel during an emergency. This task requires immediate action and basic training, making it appropriate for delegation. Performing a dressing change for a new amputee involves specialized knowledge and skills, typically performed by licensed healthcare providers. Assessing the effectiveness of medication requires critical thinking and decision-making skills that are within the scope of a licensed healthcare provider. Providing discharge instructions involves educating the patient on post-discharge care and follow-up, which is typically done by a healthcare provider to ensure clear communication and understanding.