Correct Answer: C

Rationale: The correct answer is C: fat embolism syndrome related to femur fracture. Fat embolism syndrome occurs when fat globules enter the bloodstream and travel to the lungs, causing respiratory distress. In this case, the patient's femur fracture likely led to fat embolism, explaining her dyspnea, tachypnea, crackles, and thick sputum. Choices A, B, and D do not align with the patient's presentation and history, making them incorrect. Choice A suggests smoke inhalation, which is not supported by the scenario. Choice B mentions pneumonia from bedrest, which is not a common complication of immobility. Choice D proposes hypovolemic shock from multiple trauma, which does not explain the respiratory symptoms and sputum production observed in the patient.

Correct Answer: B

Rationale: The correct answer is B because involving the client and family in developing outcomes promotes patient-centered care and increases the likelihood of achieving successful outcomes. This approach fosters collaboration, shared decision-making, and empowers the client and family in their own care. It also helps to ensure that the outcomes align with the client's values, preferences, and goals. Choices A, C, and D are incorrect because focusing solely on nursing goals without considering the client's perspective may lead to a lack of engagement and poor outcomes. Discouraging input from other healthcare providers limits the interdisciplinary approach to care, and focusing on why the nurse believes the outcome is important neglects the client's role in the decision-making process.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Lymphangitis is an inflammation of lymphatic vessels. 2. If the affected area appears to enlarge, it indicates possible worsening or spreading of the infection. 3. Nurse should notify the physician for further evaluation and treatment. 4. Red streaks extending up the arm or leg (B) are common signs of lymphangitis, not necessarily requiring immediate physician notification. 5. Additional lymph nodes becoming (C) is a normal response to infection and may not warrant immediate physician notification. 6. Liver and spleen enlargement (D) are not directly related to lymphangitis and do not require immediate notification.

Correct Answer: B

Rationale: The correct answer is B because encouraging the patient to do leg exercises within the limits of his traction promotes independence by maintaining muscle strength and mobility. This helps prevent muscle atrophy and promotes circulation. Choice A focuses on pain management but does not directly promote independence. Choice C provides assistance but does not actively involve the patient in self-care. Choice D is important for overall care but does not directly promote independence through active patient involvement.

Correct Answer: A

Rationale: Rationale: Intrinsic factor is a glycoprotein produced by the stomach that is essential for the absorption of vitamin B12 in the ileum. Without intrinsic factor, vitamin B12 absorption is impaired, leading to megaloblastic anemia. Histamine and hydrochloric acid are not directly involved in vitamin B12 absorption. Liver enzymes are not implicated in the absorption process. Therefore, the correct answer is A.