Correct Answer: C

Rationale: The correct answer is C because the patient's voluntary or involuntary status should not impact the nurse's actions when using restraints. The use of restraints should be based on the patient's behavior and the need to ensure their safety and the safety of others. Choices A, B, and D are important factors that should influence the nurse's actions. The institution's restraints/seclusion policies provide guidelines on the appropriate use of restraints, the patient's competence helps determine their understanding and ability to control their behavior, and the patient's nursing care plan guides the overall care provided, including the use of restraints if necessary.

Correct Answer: A

Rationale: Corrected Rationale: The correct answer is immobility and poor nutrition. Immobility can lead to constant pressure on certain areas of the body, while poor nutrition can impair tissue repair and regeneration, both contributing to the development of pressure ulcers. Choices B, C, and D are incorrect because while obesity, diabetes, dehydration, malnutrition, use of assistive devices, and prolonged bedrest can impact skin integrity and wound healing, they are not the primary risk factors specifically associated with pressure ulcer development.

Correct Answer: B

Rationale: The correct next step when a client develops phlebitis while receiving IV fluids is to remove the catheter and place it in another site. Phlebitis is inflammation of a vein, and leaving the catheter in the same site can lead to further complications. Monitoring the site for further swelling, as in choice A, is not enough as the source of inflammation needs to be removed. Choice C, reducing the flow rate, may not address the underlying issue causing phlebitis. Switching to oral hydration, as in choice D, is not necessary for addressing phlebitis related to IV fluid administration.

Correct Answer: A

Rationale: The correct answer is A: Chest pain, shortness of breath, and tachycardia. These are classic early signs of a pulmonary embolism. Chest pain may be sudden and sharp, worsened by deep breathing or coughing. Shortness of breath can be sudden and severe. Tachycardia (rapid heart rate) is another common symptom. Choices B, C, and D are incorrect as they do not represent typical early signs of a pulmonary embolism.

Correct Answer: B

Rationale: The correct first step before administering a blood transfusion is to verify that the client's blood type matches the blood product. This step is crucial to prevent transfusion reactions due to incompatibility. Choice A is incorrect because blood should not be administered through an IV push for a blood transfusion. Choice C is incorrect because it is not necessary for the client to eat before a blood transfusion. Choice D is incorrect because administering a diuretic is not a standard practice before starting a blood transfusion.