Correct Answer: B

Rationale: The correct answer is B because a saturated and leaking dressing indicates a potential infection risk and compromised wound healing. The nurse should revise the plan of care and change the dressing immediately to prevent complications. Waiting until 1800 (choice A) could lead to further contamination and delay in treatment. Reassessing in 2 hours (choice C) might worsen the condition. Discontinuing the plan of care (choice D) is not appropriate without addressing the immediate issue.

Correct Answer: A

Rationale: The correct answer is A because in surgical asepsis, sterile articles should not touch other sterile articles or surfaces to maintain sterility. Choice B is correct as surgical team gowns are sterile in front. Choice C is correct as any breach makes the area contaminated. Choice D is correct as sterile drapes create a sterile field.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates data validation in the nursing clinical decision-making process. The nurse assesses the time of the last dressing change and observes old and new drainage, which are relevant data points for wound care. This approach ensures that the decision to remove the dressing is based on accurate and validated information, leading to appropriate patient care. Choice B is incorrect because it relies on subjective information (increased pain and family request) rather than objective data validation. Choice C is incorrect as it involves a direct request for an order without sufficient data validation. Choice D is incorrect because elevating a leg cast based solely on a patient's report of decreased mobility does not involve thorough data validation related to the specific care needed for the patient's condition.

Correct Answer: A

Rationale: The correct answer is A: Balance. Loss of ability in balance can indicate various health issues like neurological disorders or musculoskeletal problems. The nurse can assess this by observing the patient's gait, balance while standing, and coordination. Speech (B) relates to communication abilities, judgment (C) involves decision-making skills, and endurance (D) is related to stamina and physical capacity, which are not directly linked to loss of ability.

Correct Answer: A

Rationale: The correct answer is A: Risk for transmission of infection. This is appropriate because the girl has genital herpes, which is a sexually transmitted infection (STI) that can be transmitted to others through sexual contact. Therefore, the main concern is preventing the spread of the infection to others. Pain (B) is a symptom of herpes but not the primary concern here. Health-seeking behaviors (C) may be relevant for education and prevention, but not the immediate focus. Ineffective sexuality pattern (D) is not directly related to the risk of transmission of infection in this case.