Correct Answer: B

Rationale: The most appropriate intervention for constipation is to encourage the client to increase dietary fiber intake. Fiber helps promote bowel movements and relieve constipation by adding bulk to the stool. Administering a laxative (Choice A) should not be the first-line intervention as it can lead to dependence. Encouraging rest (Choice C) is not directly helpful in relieving constipation. While administering a stool softener (Choice D) can be beneficial, increasing fiber intake is generally preferred as the initial intervention.

Correct Answer: B

Rationale: Irritability is an early sign that suctioning is needed for a client with a tracheostomy. When secretions accumulate in the airway, it can lead to discomfort and irritability in the client. Bradycardia, hypotension, and decreased oxygen saturation are usually later signs of inadequate airway clearance and oxygenation. Bradycardia may indicate severe hypoxia, while hypotension and decreased oxygen saturation are consequences of prolonged airway obstruction.

Correct Answer: A

Rationale: The correct answer is to use the cane on the stronger side. By doing so, the client will have better support and balance. Choice B is incorrect because advancing the cane and the weaker leg at the same time may lead to instability and falls. Choice C is incorrect as using the cane on the weaker side does not provide optimal support. Choice D is incorrect as advancing the cane 30 to 45 cm (12-18 in) with each step is not a standard recommendation for cane use.

Correct Answer: B

Rationale: When a client with a tracheostomy is experiencing respiratory distress, the immediate priority for the nurse is to suction the tracheostomy. This action helps clear the airway of secretions and ensures that the client can breathe effectively. Increasing the oxygen flow rate may be necessary but addressing the airway obstruction is more critical. Notifying the physician immediately is important but may cause a delay in addressing the immediate need for airway clearance. Administering a bronchodilator may help with bronchospasm but should not take precedence over ensuring a clear airway in a client with respiratory distress.

Correct Answer: B

Rationale: The correct answer is B because hair loss is a common adverse effect of chemotherapy. Options A, C, and D are incorrect. Avoiding drinking water before meals, experiencing an increase in appetite, or expecting appetite to increase are not related to the potential adverse effects of chemotherapy.