Correct Answer: A

Rationale: Step-by-step rationale: 1. The nurse should clarify discrepancies of assessment data with the client to ensure accurate information. 2. The client's denial of breathing problems conflicts with physical signs, indicating a potential lack of awareness or reluctance to disclose symptoms. 3. By clarifying with the client, the nurse can address any misunderstandings or encourage honest communication. 4. This approach promotes client-centered care and ensures a comprehensive understanding of the client's health status. Summary: - Choice A is correct as it addresses the need to clarify discrepancies with the client for accurate assessment. - Choice B is incorrect as validation with the healthcare team may not provide insight into the client's perception. - Choice C is incorrect as it does not address the need to resolve conflicting assessment data. - Choice D is incorrect as family input may not provide accurate information if the client denies symptoms.

Correct Answer: C

Rationale: The correct answer is C: An incision near the diaphragm. Following a splenectomy, an incision near the diaphragm can lead to respiratory complications due to potential irritation or injury to the diaphragm. This can result in impaired breathing and increased risk of respiratory issues such as pneumonia. A: A low platelet count is not directly related to respiratory complications following a splenectomy. B: Early ambulation is generally encouraged to prevent complications such as blood clots but does not specifically impact respiratory complications. D: Early discharge may not directly lead to respiratory complications, as long as the patient is adequately monitored postoperatively.

Correct Answer: C

Rationale: Step-by-step rationale for choice C being correct: 1. Restlessness: Indicates increased work of breathing and hypoxia. 2. Suprasternal retractions: Sign of respiratory distress. 3. paO2 of 62: Indicates severe hypoxemia, common in ARDS. Summary: A: Enlarged heart on x-ray does not directly indicate ARDS. B: Thick green sputum suggests infection, not specific to ARDS. D: Wheezes and slow respirations are not typical of ARDS, and pCO2 is normal in ARDS.

Correct Answer: D

Rationale: The correct answer is D: Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes. After a thyroidectomy, the parathyroid glands may be inadvertently damaged, leading to hypocalcemia. Muscle twitching and numbness/tingling are early signs of hypocalcemia. The nurse should monitor for these symptoms to detect and address hypocalcemia promptly. Choice A is incorrect as monitoring thyroid-stimulating hormone levels is not related to hypocalcemia. Choice B is incorrect as it describes signs of potential complications like bleeding or airway obstruction, not hypocalcemia. Choice C is incorrect as changes in voice quality and gastric issues are not specific to hypocalcemia.

Correct Answer: D

Rationale: The correct answer is D: Sitting up leaning slightly forward. This position helps prevent blood from flowing back into the throat, reducing the risk of choking and aspiration. It also allows for better drainage of blood out of the nose. Lying down with feet elevated (choice A) can increase blood flow to the head and worsen the nosebleed. Sitting up with neck extended (choice B) can lead to blood flowing into the throat. Lying down with a small pillow under the head (choice C) may cause blood to flow backward.