Correct Answer: A

Rationale: Correct Answer: A: Respiratory acidosis Rationale: 1. Respiratory acidosis is caused by inadequate ventilation leading to increased PCO₂ and decreased pH. 2. Low pH indicates acidosis, and high PCO₂ indicates respiratory component. 3. Metabolic acidosis (B) results from non-respiratory causes. 4. Respiratory alkalosis (C) is characterized by high pH and low PCO₂. 5. Metabolic alkalosis (D) is caused by non-respiratory factors with high pH.

Correct Answer: D

Rationale: The correct answer is D: Conjunctivae. Pallor is best assessed in the conjunctivae due to the transparent nature of the tissue, allowing for easy observation of paleness. The conjunctivae are the mucous membranes lining the inner surface of the eyelids and covering the sclera. Anemia can cause decreased hemoglobin levels, resulting in paleness of the mucous membranes. Assessing the scalp (A), chest (B), or axillae (C) may not provide a clear indication of pallor related to anemia. The conjunctivae offer a direct and reliable site to assess for pallor in patients with anemia.

Correct Answer: A

Rationale: The correct answer is A: Prevent clot formation. Heparin is an anticoagulant that inhibits the formation of blood clots. In DIC (Disseminated Intravascular Coagulation), there is excessive clotting throughout the body, leading to organ damage. By administering heparin, we aim to prevent further clot formation and reduce the risk of complications. Choice B is incorrect because heparin does not increase clot formation; it works to inhibit clotting. Choice C is incorrect as heparin does not directly increase blood flow to target organs. Choice D is also incorrect as heparin does not decrease blood flow to target organs; its primary role is anticoagulation.

Correct Answer: A

Rationale: The correct answer is A because measuring oxygen saturation will provide objective data to assess the client's respiratory status accurately. This step is crucial in identifying the severity of the client's breathing difficulty and determining the appropriate intervention. Encouraging deep breathing exercises (B) may worsen the client's condition if there is an underlying respiratory problem. Simply documenting the client's statement (C) without immediate action can delay necessary interventions. Providing oxygen without further assessment (D) can be harmful if the client's oxygen saturation is already high. Overall, option A is the most appropriate as it involves a proactive and evidence-based approach to address the client's reported breathing difficulty.

Correct Answer: D

Rationale: Step 1: A goal should be measurable to track progress effectively. Step 2: The statement "a measurable change in a patient's physical state" indicates a specific and quantifiable outcome. Step 3: This aligns with the SMART criteria for goal setting - Specific, Measurable, Achievable, Relevant, Time-bound. Step 4: Other choices lack the specificity and measurability required for a clear goal. Step 5: Choice A talks about restriction, which is not directly related to understanding a goal. Step 6: Choice B focuses on negative responses, which is not necessarily indicative of understanding the goal. Step 7: Choice C is vague and lacks the specificity of a measurable outcome.