When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum 'tents' when gently pinched. Which action should the nurse implement?

Correct Answer: C

Rationale: When the nurse observes that the client's skin over the sternum 'tents' when gently pinched, it is a classic sign of fluid volume deficit. The appropriate action for the nurse in this situation is to continue the planned nursing interventions aimed at restoring the client's fluid volume. This finding reinforces the need to address the fluid deficit and support the client's recovery.

Correct Answer: B

Rationale: The correct action for the nurse to take when a client coughs during tracheostomy tube suctioning is to gently withdraw the suction tubing to allow for coughing out of mucus (Option B). This is the best course of action as coughing indicates that the client's natural reflexes are working to clear the airway, and forcing suction deeper or removing it quickly can be harmful and cause hypoxia. Option A is incorrect as suctioning deeper can cause trauma to the airway and increase the risk of complications. Option C is incorrect because removing the suction quickly can lead to inadequate removal of secretions and compromise the client's airway. Option D is incorrect as inserting and removing the suction multiple times is unnecessary and can cause unnecessary trauma and irritation to the airway. In an educational context, it is crucial for nursing students to understand the importance of responding appropriately to client cues during procedures like tracheostomy tube suctioning. This scenario highlights the significance of prioritizing client safety and respecting the body's natural responses in airway management. By choosing the correct action, the nurse ensures effective care delivery while minimizing potential risks to the client.

Correct Answer: B

Rationale: In a female urethral catheterization, the healthcare provider would observe the urethral meatus between the clitoris and the vaginal orifice. This location is correct because the female urethral meatus is located anterior to the vaginal opening and posterior to the clitoris. Placing the catheter in this position ensures accurate insertion into the urethra for proper drainage of the bladder. Option A is incorrect because the urethral meatus is not located between the vaginal orifice and the anus in females. Option C, just above the clitoris, is also incorrect as the meatus is located between the clitoris and vaginal orifice, not above the clitoris. Option D, within the vaginal canal, is incorrect as the urethral meatus is separate from the vaginal canal. Understanding the correct anatomical landmarks for urethral catheterization is crucial for nursing students to perform the procedure safely and effectively. It is important to identify the correct location to prevent injury and ensure proper placement of the catheter for accurate urinary drainage.

Correct Answer: B

Rationale: The main purpose of the working phase in the nurse-patient relationship is to implement nursing interventions that are specifically tailored to achieve the expected patient outcomes. During this phase, the nurse actively works with the patient to put the care plan into action and make progress towards reaching the desired health goals. It involves the application of therapeutic communication, problem-solving, and interventions to address the patient's needs. Establishing rapport and trust is typically done in the orientation phase, while defining roles and boundaries usually occurs in the introductory phase of the relationship.

Correct Answer: A

Rationale: The first dose of the Hepatitis B vaccine is usually administered at birth in the hospital to provide early protection against the virus. Giving the vaccine at birth helps prevent perinatal transmission of Hepatitis B from an infected mother to her newborn. Therefore, it is important to administer the first dose as soon as possible after birth to ensure the best protection.