At 8:00 a.m., Nurse Corazon is preparing to change the Total Parenteral Nutrition (TPN) solution bag and tubing. The client’s central venous line is located in the right subclavian vein. The nurse would instruct the client to do which of the following during the tubing change?

Correct Answer: C

Rationale: The correct answer is C: Ask the client to take a deep breath, hold, and bear down during the tubing change. This action helps to prevent air embolism by increasing intrathoracic pressure, which reduces the risk of air being drawn into the central venous line. When the client bears down, the pressure in the thorax increases, preventing air from being sucked into the vein. Choices A, B, and D are incorrect because they do not address the specific action needed to prevent air embolism during the tubing change. Breathing normally (choice A) or turning the head to the right (choice B) will not help in preventing air embolism. Exhaling slowly and evenly (choice D) does not provide the necessary increase in intrathoracic pressure to prevent air entry into the central venous line.

Correct Answer: A

Rationale: The correct answer is A: Risk for impaired skin integrity related to immobility. The nurse's documentation indicates preventive measures taken to maintain skin integrity due to immobility, such as turning the client every 2 hours. The absence of redness and improved skin turgor show proactive skin assessment and care. Choice B is incorrect as there is no evidence of actual skin breakdown. Constipation (choice C) and disturbed body image (choice D) are not supported by the information provided. Therefore, choice A is the most appropriate nursing diagnosis based on the documented care and assessment findings.

Correct Answer: D

Rationale: The correct answer is D: Vesicles. Vesicles are small, elevated lesions filled with clear fluid, typically less than 0.5 cm in diameter. In this case, the client's presentation of elevated, round, blister-like lesions filled with clear fluid matches the description of vesicles. Pustules (A) are similar in appearance but contain pus, while papules (B) are raised, solid lesions without fluid-filled cavities. Plaques (C) are flat, raised lesions typically larger than 1 cm in diameter. Therefore, based on the specific characteristics of the lesions described in the scenario, the appropriate term to use would be vesicles.

Correct Answer: D

Rationale: The correct answer is D because pumping the cuff to around 50 mmHg above the point where the pulse is obliterated is incorrect. The correct method is to pump the cuff to about 30 mmHg above the point where the pulse disappears. Pumping too high can lead to inaccurate readings. Observing procedures for infection control (A), taking BP on both arms for comparison (B), and listening to identify Korotkoff sounds (C) are all correct methods in the assessment of blood pressure, ensuring accuracy and reliability.

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.