The nurse is caring for a female client with diarrhea. What information does the nurse teach the client about perineal care?

Correct Answer: A

Rationale: The correct answer is A: Clean the perineal area from the front to back. This is crucial to prevent the spread of bacteria from the anal area to the vaginal area, reducing the risk of urinary tract infections. Cleaning from front to back maintains hygiene and minimizes the risk of cross-contamination. B: Wearing gloves is not necessary for routine perineal care, unless there are open wounds or the nurse is at risk of exposure to bodily fluids. C: Bathing the perineal area with mild soap and water is generally recommended, but the direction of cleaning is more important to prevent infections. D: Inserting any suppository medication prior to cleaning the perineal area is not advisable as it may lead to contamination of the medication and reduce its effectiveness.

Correct Answer: B

Rationale: The correct principle involved in this situation is beneficence. Beneficence is the ethical principle that emphasizes the duty to do good and promote the well-being of others. In this case, the administration of immunizations may cause discomfort to the child, but the benefits of protection from diseases outweigh this temporary discomfort. By choosing to immunize the child, the healthcare provider is acting in the child's best interest to prevent future harm from potentially deadly diseases. This decision aligns with the principle of beneficence. A: Fidelity pertains to being faithful and keeping promises, which is not directly relevant to this situation. C: Nonmaleficence is the principle of doing no harm, but in this case, the temporary discomfort of immunization is outweighed by the long-term benefits. D: Respect for autonomy refers to respecting an individual's right to make their own decisions, which is not the primary focus in this scenario.

Correct Answer: C

Rationale: The correct answer is C because it provides a clear and accurate explanation to the client's question. ARDS is characterized by fluid accumulation in the lungs, leading to breathing difficulties. This response directly addresses the client's concern about what is happening to their body. Choice A is incorrect as not all individuals who almost drown develop ARDS. Choice B is incorrect because it describes a mechanism of injury different from ARDS. Choice D is incorrect as smoking may increase the risk of developing ARDS but is not the direct cause in this scenario. In summary, choice C is the most appropriate response as it directly addresses the client's condition and explains the underlying cause of their breathing problems related to ARDS.

Correct Answer: A

Rationale: The correct answer is A: Check the tubing for any kinks. This should be implemented first because an increase in peak airway pressure may indicate an obstruction in the tubing, causing inadequate ventilation. Checking for kinks ensures the client receives adequate oxygenation and ventilation. Suctioning for secretions (B) would be secondary if kinks are ruled out. Assessing the lip line of the ET tube (C) is important but not as urgent as checking for kinks. Sedating the client with a muscle relaxant (D) is not appropriate as the first intervention for high peak airway pressure.

Correct Answer: A

Rationale: The correct answer is A: Hypercapnic respiratory failure related to decreased ventilatory effort. Barbiturates can depress the central nervous system, leading to decreased respiratory drive and effort, resulting in hypercapnia (elevated CO2 levels) and respiratory acidosis. This can progress to respiratory failure. The other choices are incorrect because hypoxemic respiratory failure related to diffusion limitations (B) or shunting of blood (C) are not typically associated with barbiturate overdose. Hypercapnic respiratory failure related to increased airway resistance (D) is also unlikely with barbiturate overdose, as the primary mechanism is central respiratory depression.