Correct Answer: B

Rationale: The correct answer is B. Alcohol-based hand rubs are effective with a shorter rub time, typically around 20-30 seconds. Standing at the bedside for 2 minutes to rub hands thoroughly is unnecessary and can lead to wastage of resources. It's essential for the nurse to educate the UAP on proper hand hygiene techniques to ensure efficient and effective infection control practices. Choices A, C, and D are incorrect because encouraging the UAP to remain in the client's room, discussing handwashing instead of hand rubs, and questioning glove use are not the most appropriate actions in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Infection. Improper suctioning techniques can introduce pathogens, increasing the risk of infection. Choice B, Hypoxia, is incorrect as it is more related to inadequate oxygen supply. Choice C, Bleeding, is not typically associated with suctioning a tracheostomy unless done too aggressively. Choice D, Bronchospasm, is not directly linked to suctioning but may occur due to other triggers in patients with sensitive airways.

Correct Answer: C

Rationale: The correct answer is C: Use of accessory muscles. In a client with COPD receiving supplemental oxygen, the use of accessory muscles is a critical finding that requires immediate intervention. This observation indicates increased work of breathing, suggesting respiratory distress. Addressing this issue promptly is crucial to prevent further respiratory compromise. Choice A, oxygen saturation of 90%, is slightly below the normal range but may not require immediate intervention unless it continues to decrease. Choice B, a respiratory rate of 24 breaths per minute, is within normal limits for an adult and does not indicate an urgent issue. Choice D, inspiratory crackles, may be present in COPD due to secretions or inflammation but do not necessitate immediate intervention unless associated with other concerning signs.

Correct Answer: B

Rationale: The correct answer is B. Sleepiness and difficulty feeding are key signs of congenital hypothyroidism, which requires early diagnosis and treatment. Asking about immunizations (choice A) is important but not directly related to assessing hypothyroidism. The feeding method (choice C) is relevant for overall health but not specific to hypothyroidism. Inquiring about relatives with birth defects (choice D) is not the most crucial question to assess hypothyroidism in this scenario.

Correct Answer: B

Rationale: In this scenario, the client's symptoms of nausea and a significant drop in blood pressure suggest a potential right ventricular infarction. The appropriate intervention for this situation is to infuse a rapid IV normal saline bolus. This fluid resuscitation helps improve cardiac output by increasing preload, which can be beneficial in right ventricular infarction. Administering a second dose of nitroglycerin may further lower blood pressure. External chest compressions are not indicated in this case as the client has a pulse. Providing an antiemetic medication does not address the underlying issue of hypotension and potential right ventricular involvement.