Correct Answer: B

Rationale: To calculate the mL needed for the injection, divide the prescribed dose by the concentration of the medication. In this case, 30 mg ÷ 50 mg/mL = 0.6 mL. However, since the nurse should round up to ensure the full dose is administered, the correct answer is 0.7 mL. Choice A is incorrect as it is rounded down. Choice C is incorrect as it is the exact division without rounding up. Choice D is incorrect as it is rounded up too much.

Correct Answer: C

Rationale: The correct answer is C: Diagnostic reasoning. The nurse is using assessment data to analyze, interpret, and make a judgement about the patient's condition. This process involves critical thinking skills to develop a nursing diagnosis. Choice A (Assigning clinical cues) is incorrect because it refers to identifying specific signs and symptoms. Choice B (Defining characteristics) is incorrect as it pertains to the features of a diagnosed condition. Choice D (Diagnostic labeling) is incorrect because it focuses on naming a specific nursing diagnosis. Diagnostic reasoning encompasses the entire process of analyzing data, making connections, and formulating a nursing diagnosis based on critical thinking.

Correct Answer: B

Rationale: The correct answer is B: Ineffective airway clearance related to obstruction by a tumor or secretions. This takes highest priority as compromised airway can lead to respiratory distress and potential respiratory failure. Maintaining clear airways is essential for oxygenation and ventilation. Choices A, C, and D are important but do not pose immediate life-threatening risks compared to compromised airway. Disturbed body image, anxiety, and imbalanced nutrition can be addressed once the airway clearance is stabilized.

Correct Answer: B

Rationale: The correct answer is B because rifampin can cause discoloration of bodily fluids, including tears. If clients wear contact lenses, they need to be informed that the lenses may become colored due to this medication. This is important for the client's awareness and to prevent any potential harm to their eyes. A: Taking medication with meals is not necessary for rifampin administration. C: Avoiding wearing glasses is not relevant to rifampin treatment. D: Avoiding tuna, aged cheese, and red wine is not specifically related to rifampin use.

Correct Answer: D

Rationale: Autoimmunity is when the immune system mistakenly attacks the body's own cells. Choice D is correct because it reflects this key feature - the inability to differentiate self from nonself. This leads to the immune system targeting healthy tissues. Choices A, B, and C are incorrect as they do not accurately describe autoimmunity. Choice A refers to endotoxins destroying B cells, which is not the definition of autoimmunity. Choice B mentions overproduction of reagin antibody, which is not related to autoimmunity. Choice C is incorrect as autoimmunity does not involve depression of the immune response but rather an inappropriate immune response.