Nurse Lhynnette is preparing a site for the insertion of an I.V. catheter. The nurse should treat excess hair at the site by:

Correct Answer: C

Rationale: The correct answer is C: Clipping the hair in the area. Clipping the hair is the best option as it reduces the risk of skin irritation and infection compared to shaving or using a depilatory. Clipping allows for a more controlled and precise removal of hair without causing micro-cuts or irritating the skin. Leaving the hair intact (choice A) may interfere with the insertion of the I.V. catheter, while shaving (choice B) can lead to micro-cuts and increase the risk of infection. Using a depilatory (choice D) can also irritate the skin and is not recommended for I.V. site preparation.

Correct Answer: C

Rationale: The correct answer is C, the 43-year-old homeless man with a history of alcoholism. This choice is most likely to have TB due to the increased risk factors associated with homelessness, alcoholism, and compromised immune system. Homeless populations are at higher risk for TB due to crowded living conditions and poor access to healthcare. Alcoholism can weaken the immune system, making individuals more susceptible to TB infection. The other choices do not have the same level of risk factors for TB compared to the homeless man with alcoholism. A, the 16-year-old high school student, is less likely to have TB as younger age groups typically have lower rates of TB. B, the 33-year-old day-care worker, may have some exposure risk, but it is not as high as the homeless man with alcoholism. D, the 54-year-old businessman, does not have the same risk factors for TB as the homeless man with alcoholism.

Correct Answer: D

Rationale: The correct answer is D: The 75-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving L.V. diltiazem (Cardizem). This client should be assessed first because atrial fibrillation can lead to serious complications like stroke or heart failure. Assessing this client allows for prompt intervention to stabilize the heart rhythm. Choice A can be ruled out as the client's vital signs are stable and the condition has been present for 2 days. Choice B should be assessed next due to the critically low blood pressure, but the client with atrial fibrillation takes priority. Choice C, although receiving heparin, does not have an acute condition like atrial fibrillation that requires immediate attention.

Correct Answer: D

Rationale: The correct answer is D because after receiving a subarachnoid block, the client should remain supine for the specified time to prevent complications like a sudden drop in blood pressure. This position helps maintain proper blood flow to the brain and spinal cord. A is incorrect because maintaining hydration is important postoperatively. B is incorrect as there is no specific reason to avoid milk products. C is incorrect as blood in urine is not a common complication of a subarachnoid block and would not be the most important instruction at this time.

Correct Answer: C

Rationale: The correct answer is C: Deep vein thrombosis (DVT) due to immobility of the ipsilateral side. After a stroke, immobility can lead to blood pooling in the deep veins, increasing the risk of DVT. This can cause swelling in the affected limb. Choices A and B do not directly relate to swelling post-stroke. Choice D is not relevant to the situation described. Therefore, the correct choice is C due to the increased risk of DVT from immobility post-stroke.