Correct Answer: C

Rationale: The correct answer is C because respirations of 16 are measurable and quantifiable, making them objective data. Subjective data, like choices A, B, and D, are based on the patient's feelings or experiences and cannot be measured or observed directly. Choice A is subjective as it relies on the patient's self-report. Choice B is subjective as it describes a symptom reported by the patient. Choice D is subjective as it reflects the patient's feeling of nausea. Objective data is essential for making accurate clinical assessments and decisions.

Correct Answer: D

Rationale: The correct answer is D: Chronic ache or pain. Persistent cough and chronic ache or pain are both common warning signs of cancer. Chronic pain can be a symptom of various types of cancer, signaling the presence of a tumor or cancerous growth. It is important for the client to seek medical evaluation to rule out any underlying serious condition. A: Persistent nausea is not typically considered a common warning sign of cancer. While it can be a symptom in certain types of cancer or due to treatment side effects, it is not as prominent as chronic ache or pain. B: Indigestion is a common symptom that can be caused by various non-cancer-related issues such as dietary habits, stress, or gastrointestinal disorders. It is not typically considered a direct warning sign of cancer. C: Rash is generally not a common warning sign of cancer. Rashes are more commonly associated with skin conditions, allergic reactions, or infections rather than being an indicator of cancer.

Correct Answer: D

Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This is the most appropriate nursing diagnosis for a patient with pneumonia and lower lobe infiltrates. The rationale is that pneumonia causes inflammation and fluid accumulation in the alveoli, impairing the exchange of oxygen and carbon dioxide in the lungs. This directly affects gas exchange. Choice A is incorrect because ineffective breathing pattern is a broad nursing diagnosis that does not specifically address the underlying issue of impaired gas exchange in pneumonia. Choice B is incorrect as the risk of infection related to the chest x-ray procedure is unrelated to the patient's current condition of pneumonia. Choice C is also incorrect as dehydration does not directly correlate with the patient's diagnosis of pneumonia and lower lobe infiltrates.

Correct Answer: B

Rationale: The correct answer is B: Have patient lie down. When a patient experiences dehiscence (surgical wound separation), lying down helps reduce tension on the wound, minimizing the risk of further tearing. This position also allows the nurse to assess the wound properly. Choice A is incorrect because sitting upright can increase intra-abdominal pressure, worsening the dehiscence. Choice C is incorrect as slowing IV fluids is not a priority in managing dehiscence. Choice D is incorrect because obtaining a sterile suture set should only be done by a healthcare provider and is not the immediate action needed for dehiscence.

Correct Answer: A

Rationale: The correct answer is A: Risk for impaired skin integrity. Myocardial infarction, hypertension, and progressive systemic sclerosis can lead to impaired circulation and skin breakdown. Clients with these conditions are at risk for pressure ulcers due to decreased blood flow and compromised skin integrity. The other options, B: Imbalanced nutrition, C: Constipation, and D: Ineffective thermoregulation, do not directly relate to the client's conditions or the potential complications associated with them. Therefore, the most appropriate nursing diagnosis for this client would be A: Risk for impaired skin integrity.