What action facilitates venous blood flow during a sponge bath?

Correct Answer: A

Rationale: The correct answer is A because rubbing with long smooth strokes from distal to proximal parts of the extremities follows the direction of venous blood flow towards the heart, aiding venous return. This action helps prevent blood pooling in the extremities. Circular massage strokes (B) may not be as effective in promoting venous return. Rubbing with short strokes from proximal to distal parts (C) goes against the natural flow of venous blood. Smooth long strokes alternating with chopping motions (D) may not consistently promote venous blood flow in the correct direction.

Correct Answer: B

Rationale: The correct answer is B: 15 seconds. Suction attempts should generally be limited to 15 seconds to prevent hypoxia and tissue damage. Prolonged suctioning can lead to decreased oxygenation and potential trauma to the airway. Choice A (5 seconds) may not be sufficient for effective suctioning. Choice C (30 seconds) and D (1 minute) exceed the recommended time limit and increase the risk of complications. Therefore, choice B is the most appropriate duration for a suction attempt.

Correct Answer: D

Rationale: The correct first action is D: Consult with the primary health care provider (PHCP) regarding initiation of oxygen therapy. This is because the client is showing signs of a potential transfusion reaction, likely a pulmonary embolism. The client's rapid heart rate, bounding pulse, and crackling sound at the base suggest a possible pulmonary issue. Oxygen therapy is crucial to improve oxygenation and stabilize the client's condition. Consulting with the PHCP ensures timely intervention and appropriate management. A: Maintaining bed rest with legs elevated would not address the potential respiratory distress the client is experiencing. B: Placing the client in high-Fowler's position may help improve oxygenation, but consulting the PHCP for oxygen therapy is the priority. C: Increasing the rate of IV fluids is not the priority when the client is showing signs of a potential serious complication like a pulmonary embolism.

Correct Answer: D

Rationale: The correct answer is D. When administering a subcutaneous injection to an obese patient, it is best for Nurse Andrae to spread or pinch the skin at the injection site and inject the needle at a 45-90 degree angle. This allows for proper medication absorption due to the thicker layer of subcutaneous fat in obese patients. Pinching the skin helps ensure the medication is injected into the subcutaneous tissue rather than the muscle. Options A and B are not ideal for obese patients as they may not penetrate the thicker layer of fat effectively. Option C, the Z track method, is typically used for intramuscular injections and is not necessary for subcutaneous injections in obese patients.

Correct Answer: C

Rationale: The correct answer is C: Ask the client to take a deep breath, hold, and bear down during the tubing change. This action helps to prevent air embolism by increasing intrathoracic pressure, which reduces the risk of air being drawn into the central venous line. When the client bears down, the pressure in the thorax increases, preventing air from being sucked into the vein. Choices A, B, and D are incorrect because they do not address the specific action needed to prevent air embolism during the tubing change. Breathing normally (choice A) or turning the head to the right (choice B) will not help in preventing air embolism. Exhaling slowly and evenly (choice D) does not provide the necessary increase in intrathoracic pressure to prevent air entry into the central venous line.