Once the client is in position the nurse visualizes the anus and is ready to insert the rectal tip. She is doing the procedure correctly when she directs the rectal tip to the:

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: 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.

Correct Answer: B

Rationale: The correct answer is B: Respiratory rate. A sudden change in the client's respiratory rate, especially if the client becomes profoundly short of breath, indicates a critical change in condition such as respiratory distress or failure. This is a priority assessment as it directly relates to the client's oxygenation and respiratory status. In this scenario, the client's increased respiratory rate of 26 breaths per minute, along with the symptoms of profound shortness of breath and gray skin color, indicates potential respiratory compromise. Monitoring the respiratory rate would have alerted the nurse first to the client's deteriorating condition. Summary of other choices: A: Heart rate - Although an elevated heart rate of 110 bpm is present, it is less indicative of respiratory distress compared to the respiratory rate in this situation. C: Blood pressure - The blood pressure of 120/70 is within normal range and may not be the first indicator of respiratory distress. D: Temperature - A temperature of 100.4 degrees Fahrenheit is slightly

Correct Answer: C

Rationale: The correct answer is C: Giving away valued personal items. This is a critical behavioral cue for suicide risk as it indicates a potential desire to say goodbye or tie up loose ends before attempting suicide. It is a warning sign that should be taken seriously and addressed promptly. Choices A, B, and D are not directly related to suicide risk assessment and do not specifically indicate imminent danger. Angry outbursts, fear of being alone, and experiencing a loss are important considerations in mental health but do not directly signal an immediate risk of suicide.