Correct Answer: B

Rationale: Step-by-step rationale: 1. CD4+ cells are a type of white blood cell crucial for immune function. 2. HIV targets and destroys CD4+ cells, leading to immune system damage. 3. Measuring CD4+ levels helps determine the extent of this damage. 4. Therefore, the correct answer is B. Summary: A: Presence of opportunistic infections - CD4+ levels indirectly affect susceptibility, but not measured for this purpose. C: Level of the viral load - Measured separately from CD4+ levels. D: Resistance to antigens - CD4+ levels do not directly indicate resistance.

Correct Answer: A

Rationale: Step 1: Reassessing the wound and client's condition allows the nurse to identify any factors contributing to the lack of improvement. Step 2: It helps determine if the current care plan needs modifications or if there are underlying issues affecting healing. Step 3: This step ensures a comprehensive evaluation before making any changes to the care plan, promoting evidence-based practice. Step 4: Choosing this option aligns with the nursing process of assessment, which is crucial for making informed decisions in client care. Summary: Option A is correct as it emphasizes the importance of reassessment to gather more information and make informed decisions. Discontinuing the care plan (Option B) without assessment can be harmful. Increasing dressing changes (Option C) may not address the underlying issue. Referring immediately (Option D) may be premature without reassessment.

Correct Answer: A

Rationale: The correct answers are i. Keep the patient’s call light within reach, iii. Avoid use of throw rugs, and iv. Maintain the patient’s bed in a low position. 1. Keeping the call light within reach ensures the patient can easily call for assistance, reducing the risk of falls. 2. Avoiding throw rugs prevents tripping hazards that can lead to falls. 3. Maintaining the bed in a low position reduces the risk of injury if the patient falls out of bed. The incorrect choices: - Choice B includes answer 3 (Avoid use of throw rugs), which is correct, but also includes answer 6 (Provide a cane or walker for ambulation), which is not specific to fall prevention. - Choice C includes answer 2 (Apply a soft vest restraint when the patient is in bed), which can increase the risk of falls due to restricted movement. - Choice D includes answers that are not directly related to fall prevention, such as 2 (Apply a soft vest

Correct Answer: C

Rationale: The correct answer is C: Ask the patient about the facial grimacing with movement. This is the initial action because the discrepancy between the patient's verbal pain level and non-verbal cues needs clarification. By directly asking the patient about the facial grimacing, the nurse can gather more information to assess the actual pain level accurately. This step ensures a comprehensive understanding of the patient's pain experience and guides further interventions. Incorrect choices: A: Proceed to the next patient’s room to make rounds - This choice neglects the need to address the discrepancy in the patient's pain assessment. B: Determine the patient does not want any pain medicine - Assuming the patient's preference without further assessment can lead to inadequate pain management. D: Administer the pain medication ordered for moderate to severe pain - Without clarifying the reason behind the facial grimacing, administering pain medication may not be appropriate and could result in unnecessary medication use.

Correct Answer: D

Rationale: The correct answer is D: A bleeding disorder. Thoracentesis involves inserting a needle into the pleural space to remove fluid. A bleeding disorder increases the risk of excessive bleeding during the procedure. This can lead to complications such as hematoma formation, pneumothorax, or even life-threatening bleeding. It is crucial to assess and address bleeding disorders before performing thoracentesis to ensure the safety of the client. A: A seizure disorder is not a contraindication for thoracentesis unless uncontrolled seizures could compromise the safety of the procedure. B: Anemia alone is not a contraindication for thoracentesis, as it does not directly increase the risk of complications during the procedure. C: Chronic obstructive pulmonary disease is not a contraindication for thoracentesis unless it is severe and compromises the client's ability to tolerate the procedure.