Correct Answer: C

Rationale: In this scenario, the best initial nursing action is to allow several minutes for the client to respond. This approach respects the cultural norms of the client, as in some cultures, direct eye contact may be perceived as disrespectful or intrusive. By giving the client time to gather his thoughts and respond at his own pace, the nurse promotes effective communication and demonstrates cultural sensitivity. Asking for assistance from social services to find a Korean interpreter (Choice A) may be necessary for further communication but is not the best initial action. Establishing indirect eye contact (Choice B) may still make the client uncomfortable. Repeating the question using simpler language (Choice D) may not address the underlying cultural aspect affecting the client's response.

Correct Answer: D

Rationale: The correct action for the nurse to implement is to document the assessment data. In this scenario, the findings indicate that the partial rebreather mask is functioning correctly as the reservoir bag should not deflate completely during inspiration. Additionally, the client's respiratory rate of 14 breaths/minute falls within the normal range. There is no need to encourage the client to take deep breaths, as the respiratory rate is normal, and doing so may disrupt the client's breathing pattern. Removing the mask to deflate the bag or increasing the liter flow of oxygen are unnecessary actions based on the assessment findings.

Correct Answer: A

Rationale: The correct action for the nurse to implement next is to collect a clean-catch specimen. This is essential to diagnose the cause of the client's symptoms accurately before initiating any treatment. Administering antibiotics (Choice B) without confirming the diagnosis through a specimen collection can be inappropriate and potentially harmful. Performing a bladder scan (Choice C) may not provide the necessary information to identify the specific cause of the symptoms. Increasing the client's fluid intake (Choice D) is a general recommendation and may not address the underlying issue causing the symptoms.

Correct Answer: D

Rationale: The 82-year-old client with Alzheimer's disease and a newly fractured femur should receive the most care hours by a registered nurse because they are at the highest risk for injury and complications. The client's age, diagnosis of Alzheimer's disease, and the presence of a newly fractured femur along with the Foley catheter and wrist restraints indicate a need for close monitoring and care. Choice A is less critical as the client is stable post-appendectomy. Choice B, though experiencing symptoms, is not at the same level of risk as the client in Choice D. Choice C, while requiring oxygen support, does not have the same level of acuity and complexity as the client in Choice D.

Correct Answer: C

Rationale: In cases of shoulder dystocia, the priority intervention is to assist the client in sharply flexing her thighs up against the abdomen (McRoberts maneuver). This action helps to widen the pelvic outlet. Encouraging the client to move to a hands-and-knees position may also be beneficial in some cases but is not the first-line intervention. Preparing for an emergency cesarean birth and applying suprapubic pressure are not appropriate initial interventions for shoulder dystocia.