The nurse auscultates a systolic murmur in the second intercostal space to the right of the sternum while performing a cardiac assessment on a client. The nurse interprets this finding as:

Choice A reason: I will call dietary to bring you breakfast is not the best response by the nurse. This response may imply that the nurse is willing to compromise the test results or the client's safety by allowing them to eat before the test. The nurse should explain the rationale for fasting and offer the client some water or ice chips if allowed.

Choice B reason: Food may interact with the dye that is used for the test is not the best response by the nurse. This response may be partially true, but it is not specific or clear enough to justify the need for fasting. The nurse should explain that food can affect the absorption and distribution of the radioactive tracer that is injected into the bloodstream for the test, and that eating can also interfere with the quality of the images.

Choice C reason: I will ask the health care provider if the test can be rescheduled is not the best response by the nurse. This response may suggest that the nurse is not confident or knowledgeable about the test protocol or the client's condition. The nurse should explain the importance and urgency of the test and reassure the client that they will be able to eat after the test is done.

Choice D reason: The procedure is usually completed on an empty stomach is the best response by the nurse. This response is accurate and concise, and it informs the client of the standard preparation for the test. The nurse should also provide more details about the test procedure and the expected duration, and answer any questions or concerns that the client may have.

Choice A reason: Placing a pad under the buttocks is not the best intervention to help prevent skin breakdown. A pad can absorb some of the moisture and protect the bed linen, but it can also trap heat and bacteria and cause irritation and infection of the skin.

Choice B reason: This is the best intervention to help prevent skin breakdown. Checking the rectal area for soiling frequently allows the nurse to remove any fecal matter and clean the skin as soon as possible. This reduces the exposure of the skin to moisture, acidity, and enzymes that can damage the skin integrity and cause inflammation and ulceration.

Choice C reason: Washing the buttocks with strong soap and water is not the best intervention to help prevent skin breakdown. Strong soap can strip the natural oils and protective barrier of the skin and make it more vulnerable to injury and infection. The nurse should use mild soap and water or a pH-balanced cleanser and pat the skin dry gently.

Choice D reason: Placing the call bell in the client's reach is not the best intervention to help prevent skin breakdown. A mentally impaired client may not be able to use the call bell or communicate their needs effectively. The nurse should not rely on the client's ability to ask for help, but rather check on the client regularly and provide appropriate care.