Elise is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hour. The nurse anticipates that which prescription regarding the PN solution will accompany the diet prescription?

Correct Answer: B

Rationale: The correct answer is B: Decrease PN rate to 50 mL/hour. This is because as Elise transitions to solid food, her need for parenteral nutrition will decrease. Decreasing the PN rate to 50 mL/hour gradually weans her off PN while ensuring she is still receiving some nutrition. Choice A is incorrect as abruptly discontinuing PN can lead to nutritional deficiencies and potential complications. Choice C is incorrect as starting normal saline is unrelated to the weaning process from PN. Choice D is incorrect as continuing the current infusion rate would not facilitate the transition to solid food.

Correct Answer: B

Rationale: The correct answer is B: Umbilicus. When performing a rectal procedure, the rectal tip should be directed towards the umbilicus for proper insertion into the rectum. The umbilicus is used as a landmark to guide the rectal tip into the correct position. Directing the tip towards the sigmoid (A) or large intestine (D) would be incorrect as it may lead to improper insertion. Choosing the rectum (C) is not specific enough as the rectal tip needs to be aimed towards a more precise point for accurate placement.

Correct Answer: C

Rationale: The correct nursing diagnosis of "Excessive fluid volume" takes highest priority for the client with chronic renal failure due to the presenting signs and symptoms of fluid overload: high blood pressure, neck vein distention, and bibasilar crackles indicating fluid in the lungs. Managing fluid volume is crucial to prevent complications such as pulmonary edema and worsening renal function. Fear (A) is not the priority as physiological needs should be addressed first. Urinary retention (B) is not the priority as the client's symptoms are more indicative of fluid overload rather than urinary retention. Self-care deficient: Toileting (D) is not the priority as it does not address the immediate physiological threat posed by excessive fluid volume.

Correct Answer: A

Rationale: The correct answer is A: By indenting the skin ½" to ¾" (1.3 to 1.9 cm). Light palpation is performed by gently pressing down on the skin with the fingertips to a depth of ½" to ¾" to assess superficial structures. This depth allows the nurse to feel for tenderness, texture, temperature, and moisture without causing discomfort or disrupting deeper tissues. Choices B, C, and D are incorrect because they describe depths or techniques that are too deep or not appropriate for light palpation, which should be gentle and shallow. Option B (1" to 2") and C (1" using both hands) would be too deep and could potentially cause discomfort to the patient. Option D (1" and then releasing quickly) does not maintain the consistent light pressure needed for accurate assessment of superficial structures.

Correct Answer: D

Rationale: The correct answer is D: Pull the pinna of the ear backwards and upwards. This direction allows for proper alignment of the ear canal with the tympanic membrane, ensuring accurate temperature measurement. Pulling the pinna backwards and upwards straightens the ear canal for better contact with the thermometer, leading to a more precise reading. Choices A, B, and C would not facilitate optimal alignment for accurate tympanic temperature measurement and could potentially result in an incorrect reading.