Correct Answer: C

Rationale: Patients with impaired awareness may exhibit symptoms such as being semiconscious, overfatigued, disoriented, confused, or demonstrating symptoms of drug or alcohol withdrawal. A patient who cannot care for themselves at home does not necessarily indicate impaired awareness, as this could be due to physical limitations or lack of support, rather than a cognitive deficit.

Correct Answer: A

Rationale: Pulse pressure is calculated by subtracting the diastolic pressure from the systolic pressure. In this case, the systolic pressure is 150 and the diastolic pressure is 96. Therefore, the pulse pressure is 150 - 96 = 54. Pulse pressure represents the force generated by the heart with each contraction and is an important indicator of cardiovascular health.

Correct Answer: A

Rationale: Massaging a reddened area can cause further tissue damage by increasing pressure on already compromised skin. The other options, such as using specialized mattresses, adhering to repositioning schedules, and maintaining good skin care, are all recommended strategies to prevent pressure ulcers by reducing pressure and friction on vulnerable areas of the skin.

Correct Answer: A

Rationale: The patient's symptoms of shortness of breath, orthopnea, thick, tenacious secretions, and a dry hacking cough all point towards a potential airway clearance issue. This makes option A, 'Ineffective airway clearance related to thick, tenacious secretions,' the most appropriate nursing diagnosis. It directly addresses the thick secretions and suggests a potential cause of the breathing difficulty the patient is experiencing.

Correct Answer: A

Rationale: The correct answer is A because there are contraindications for chest X-rays, such as pregnancy or concerns about radiation exposure. Patients may need to remove jewelry and metallic objects to prevent interference with the imaging. While a signed consent is typically not required for a routine chest X-ray, there are specific situations where consent may be necessary. It is essential for patients to follow fasting instructions before certain types of chest X-rays to obtain accurate results.