The nurse is preparing to take vital signs in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the client's temperature?

Correct Answer: B

Rationale: When assessing a client's temperature, the method chosen must be accurate, safe, and appropriate for the client's condition. In this scenario, the client is alert but has dehydration secondary to vomiting and diarrhea, which suggests recent or ongoing gastrointestinal disturbances. The oral route (A) is generally accurate but is contraindicated in this case because vomiting increases the risk of aspiration, and residual nausea or oral irritation could affect the reading or patient comfort. The axillary route (B) is a safer alternative, as it is non-invasive and avoids the gastrointestinal system, though it may be slightly less accurate (typically 0.5°C lower than oral). It is suitable for an alert client who can cooperate by keeping the thermometer in place. The radial option (C) is incorrect because it refers to pulse assessment, not temperature. Heat-sensitive tape (D) is less precise and not a standard method for clinical vital sign monitoring in a hospital setting. Given the client's condition, axillary measurement balances safety and reliability, making B the best choice.

Correct Answer: C

Rationale: Cheyne-Stokes respiration is alternating apnea and hyperpnea (C), per its definition common in dying or heart failure. It's not sleep-specific (A), not normal (B), nor from obstruction (D) it's neurological. C accurately describes its cyclic pattern, making it the true statement.

Correct Answer: C

Rationale: Chemotherapy (C) isn't physical care for dying clients aims cure, not comfort, per terminal care. Positioning (A), mouth care (B), and pain management (D) enhance comfort. C contradicts palliative goals, making it the non-care.

Correct Answer: D

Rationale: Keeping a 30-minute check promise is fidelity (D) honoring commitment, per ethics. Autonomy (A) respects choice, beneficence (B) does good, justice (C) ensures fairness not promise-based. D reflects trust-building, making it correct.

Correct Answer: C

Rationale: Telling media about Mr. Gary's condition without consent is invasion of privacy (C) exposing private info, per law. Malpractice (A) and negligence (B) are care-based, battery (D) touch-based. C fits privacy violation, making it correct.