Correct Answer: B

Rationale: The correct answer is B because during outcome identification and planning, it is crucial to prioritize problems that require immediate attention to ensure patient safety and well-being. By asking what problems need immediate attention, nurses can focus on addressing urgent issues first. Choice A focuses on data clustering for problem identification, choice C is related to defining characteristics for nursing diagnoses, and choice D pertains to documentation, which are important but not directly related to prioritizing immediate problems.

Correct Answer: B

Rationale: The correct answer is B: To prevent cerebrospinal fluid (CSF) leakage. 1. Positioning is crucial to prevent CSF leakage as the spinal block is administered into the sub-arachnoid space where CSF is present. 2. Incorrect Answers: A: Positioning is not related to preventing confusion in this context. C: Seizures are not typically associated with spinal block anesthesia. D: Cardiac arrhythmias are not directly impacted by the client's positioning for a spinal block.

Correct Answer: D

Rationale: The correct answer is D, suggesting the use of glasses or contact lenses. This is because as older clients experience lens changes associated with aging, they may develop presbyopia or other vision issues that can be corrected with corrective lenses. Glasses or contact lenses can help improve their vision and quality of life. A, offering teaching aids with large-sized letters, may be helpful for clients with visual impairments but may not directly address the specific lens changes associated with aging. B, suggesting reduced visual activity, is not beneficial as it may further limit the client's engagement in daily activities and social interactions. C, suggesting the use of eye drops for comfort, may provide temporary relief for dry eyes but does not address the underlying lens changes affecting vision.

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: C

Rationale: The correct answer is C: 15 to 20 g of a fast-acting carbohydrate such as orange juice. In this scenario, the client is experiencing hypoglycemia, which can lead to confusion and abnormal behavior. Administering fast-acting carbohydrates like orange juice will help quickly raise the blood sugar levels. This is the first-line treatment for conscious patients with hypoglycemia. Choice A (I.M. or subcutaneous glucagon) is used for unconscious patients or when oral intake is not possible. Choice B (I.V. bolus of dextrose 50%) is too aggressive for a conscious patient and may lead to complications. Choice D (10 U of fast-acting insulin) would further lower the blood sugar levels and worsen the situation. Administering fast-acting carbohydrates is the safest and most effective approach for conscious patients with hypoglycemia to quickly raise their blood sugar levels and resolve their symptoms.