Correct Answer: C

Rationale: Decreased level of consciousness: Patients with a decreased level of consciousness (e.g., sedated, comatose, or confused patients) are at higher risk for pressure ulcers due to immobility, lack of repositioning, and unawareness of discomfort. Shortness of breath: While respiratory issues can reduce oxygenation and indirectly affect healing, shortness of breath is not a direct risk factor for pressure ulcer development. Adequate dietary intake: Adequate nutrition prevents pressure ulcers rather than increasing the risk. Poor dietary intake, particularly protein and vitamin deficiencies, is a risk factor. Muscular pain: While pain can limit movement, it is not a primary risk factor for pressure ulcer development. Immobility and prolonged pressure are the key contributors.

Correct Answer: A

Rationale: Pressure points: Pressure points (e.g., sacrum, heels, elbows, shoulders, hips) are at the highest risk for breakdown, ulcers, and impaired circulation. This makes them the priority assessment for skin integrity. Pulse points: While checking pulses is important for circulatory assessment, it is not directly related to skin integrity assessment. Breath sounds: Breath sounds assess respiratory function and are not a direct indicator of skin integrity. Bowel sounds: Bowel sounds assess gastrointestinal function and are not relevant in a skin integrity assessment.

Correct Answer: A

Rationale: Tell the client to blow his/her nose gently before the instillation of the drops: Blowing the nose clears the nasal passages, allowing the medication to reach the mucosa effectively. Assist the client to a side-lying position: The correct position is head tilted backward (supine with neck hyperextended) or head tilted slightly to the side to ensure proper absorption. A side-lying position is not appropriate for nasal drops. Hold the dropper 2 cm (1 inch) above the nares: The dropper should be placed just inside the nostril without touching it to prevent contamination. Holding it too high may cause the drops to miss the nasal mucosa. Instruct the client to stay in the same position for 2 minutes: Remaining in position for at least 5 minutes allows the medication to be absorbed without draining out of the nasal cavity.

Correct Answer: A

Rationale: Assessing changes in body temperature: The RN is responsible for assessing trends in temperature and identifying potential clinical implications (e.g., infection, sepsis, or medication reactions). Being aware of the usual values for the patient: While knowing baseline values is important, this is not solely an RN responsibility. Nursing assistants and other healthcare providers also note baseline values. Obtaining temperature measurements at ordered frequency: This task can be delegated to a nursing assistant or licensed practical nurse (LPN), as it is a routine task that does not require assessment. Using an appropriate route and device: While the RN ensures correct procedures are followed, this specific task can also be performed by trained assistive personnel. The RN focuses on interpretation and intervention.

Correct Answer: A,B,D,E

Rationale: Rectal: The rectal route provides a reliable measure of core body temperature because of its proximity to major blood vessels. Urinary Bladder: A temperature-sensing urinary catheter can provide continuous monitoring of core temperature, especially in critical care settings. Esophagus: Esophageal temperature monitoring is used in intubated patients and cardiac surgery patients to measure core temperature accurately. Pulmonary Artery: A pulmonary artery catheter (Swan-Ganz catheter) directly measures blood temperature from the heart, making it the most accurate core temperature measurement. Temporal Artery: While temporal artery thermometers are non-invasive and commonly used, they measure skin temperature, which is not a true core temperature.