Correct Answer: C

Rationale: The correct answer is C: Maintaining the integrity of the urinary system. This is crucial in preoperative preparation for a client with malignant tumors to prevent complications such as urinary obstruction or infection. Assessing symptoms of peritonitis (B) is important but not as critical as ensuring urinary system integrity. Insertion of an ostomy pouch (A) and nasogastric tube diversion procedure (D) may be necessary interventions for some cases, but they are not as essential as ensuring the urinary system's integrity to prevent serious complications.

Correct Answer: D

Rationale: The correct answer is D - Patency of airway and adequacy of respiration. This is the most important assessment during the acute stage of an unconscious patient like Mr. Franco because maintaining a clear airway and ensuring proper breathing are crucial for sustaining life. Without a patent airway and adequate respiration, the patient's oxygen supply could be compromised, leading to serious complications such as hypoxia or respiratory failure. Monitoring the airway and respiratory status takes precedence over other assessments in this scenario. A: Level of awareness and response to pain - While important, assessing level of awareness and response to pain is secondary to ensuring a patent airway and adequate respiration in an unconscious patient. B: Papillary reflexes and response to sensory stimuli - While these assessments provide valuable information about neurological function, they are not as critical as maintaining a clear airway and proper breathing in an unconscious patient. C: Coherence and sense of hearing - Coherence and sense of hearing are not as vital as

Correct Answer: A

Rationale: The correct answer is A because assessment data should be collected continuously to ensure timely detection of any changes in the client's condition. This allows for prompt interventions and prevents complications. Choice B is incorrect as assessment should be ongoing and not limited to specific times. Choice C is incorrect as the frequency of assessment should be based on client needs, not a fixed schedule. Choice D is incorrect as assessments should not be limited to certain times but should be ongoing to provide comprehensive care.

Correct Answer: A

Rationale: The correct answer is A: Failing to involve the client in the planning process. This is because involving the client in the planning process is crucial for promoting client-centered care and ensuring that the outcomes are realistic and aligned with the client's goals. By engaging the client, the nurse can better understand their preferences and values, leading to more effective planning and goal setting. Choice B is incorrect as collecting data to establish a database is related to assessment, not outcome identification and planning. Choice C is incorrect as stating specific and measurable outcomes based on nursing diagnoses is actually a key component of effective outcome identification and planning. Choice D is incorrect as writing clear nursing orders, although important, is more related to implementation rather than outcome identification and planning.

Correct Answer: C

Rationale: The correct answer is C because subjective data refers to information provided by the patient based on their feelings, perceptions, and experiences. In this case, the patient describing excitement about discharge is subjective data as it reflects the patient's emotional state. The other choices, A, B, and D, are considered objective data because they are observable and measurable by the nurse. The patient's temperature can be measured (A), the wound appearance can be visually assessed (B), and the patient pacing the floor is an observable behavior (D). Therefore, these choices are not subjective data.