The correct answer is choice A. Applying warm compresses to the incision site is anticipated for the client, as it can help reduce swelling and pain.

The other choices are contraindicated for the following reasons:

• Choice B: Maintaining bed rest for 2 days postoperatively is contraindicated, as it can increase the risk of complications such as deep vein thrombosis, pulmonary embolism, and pneumonia. The client should be encouraged to ambulate as soon as possible after surgery.
• Choice C: Irrigating indwelling urinary catheter with 50 mL of normal saline is contraindicated, as it can introduce bacteria into the bladder and cause infection. The catheter should be kept patent and draining without irrigation unless there is a specific order from the provider.
• Choice D: Administering enema to relieve constipation is contraindicated, as it can increase the pressure in the pelvic area and cause bleeding or damage to the surgical site. The client should be given stool softeners and laxatives to prevent constipation.
• Choice E: Placing a blanket roll under the client’s knees while in bed is contraindicated, as it can impair blood circulation and cause thrombophlebitis. The client should avoid flexing the knees excessively and elevate the legs slightly when lying down.

Answer is… Stay with the client for the first 15 min of the transfusion and Document the blood product transfusion in the client’s medical record are indicated nursing actions for the client. Obtain the first unit of packed RBCs from the blood bank is also indicated, but it should be done before starting the transfusion. Titrate the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg and Start an IV bolus of lactated Ringer’s solution are not indicated nursing actions for the client.

Explanation:.

• Staying with the client for the first 15 min of the transfusion is indicated because this is when most adverse reactions occur and the nurse should monitor the client’s vital signs and symptoms closely.
• Documenting the blood product transfusion in the client’s medical record is indicated because this is part of the legal and ethical responsibility of the nurse and it provides a record of the type, amount, duration, and outcome of the transfusion.
• Obtaining the first unit of packed RBCs from the blood bank is indicated because this is part of the preparation for the transfusion and it ensures that the blood product is compatible, fresh, and available. However, this should be done before starting the transfusion, not after.
• Titrating the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg is not indicated because this may cause fluid overload or hemolysis in the client who already has a low blood pressure and a high heart rate. The rate of infusion should be based on the client’s condition, weight, and response to the transfusion, not on a fixed target.
• Starting an IV bolus of lactated Ringer’s solution is not indicated because this may cause electrolyte imbalance or hemolysis in the client who already has a positive H. pylori test and a history of gastrointestinal bleeding. The only fluid that should be infused with blood products is 0.9% NaCl (normal saline) because it has a similar osmolarity and pH as blood and it prevents clotting or hemolysis.

Answer is…

The following provider prescriptions are anticipated or contraindicated for the client:.

• Insert an indwelling urinary catheter. Anticipated. This prescription is anticipated because the client may have oliguria or anuria due to dehydration, hypovolemia, or renal impairment caused by pancreatitis. A urinary catheter can help monitor the urine output and fluid status of the client.
• Insert a nasogastric tube and maintain low intermittent suction. Anticipated. This prescription is anticipated because the client may have nausea, vomiting, and abdominal distension due to pancreatitis. A nasogastric tube can help decompress the stomach, reduce pancreatic stimulation, and prevent aspiration.
• Administer lactated Ringer’s 1 L via IV bolus. Anticipated. This prescription is anticipated because the client may have hypovolemia, hypotension, and electrolyte imbalances due to pancreatitis. Lactated Ringer’s solution can help restore fluid and electrolyte balance, improve tissue perfusion, and prevent shock.
• Administer famotidine 20 mg via intermittent IV infusion twice daily. Anticipated. This prescription is anticipated because the client may have gastric hypersecretion and peptic ulcer disease due to pancreatitis. Famotidine is a histamine-2 receptor antagonist that can help reduce gastric acid production, protect the gastric mucosa, and promote healing of ulcers.

This is because rubella is a highly contagious viral infection that can cause serious harm to the developing fetus if the pregnant person gets infected. Rubella can cause congenital rubella syndrome, which can result in hearing and vision loss, heart defects and other serious conditions in newborns.

Choice A is wrong because aspirin should not be given to children or adolescents with viral infections, as it can cause Reye’s syndrome, a rare but potentially fatal condition that affects the liver and brain.

Choice C is wrong because rubella does not require airborne precautions, which are used for diseases that can spread through very small droplets that can remain in the air for long periods of time, such as tuberculosis or measles. Rubella spreads through direct contact with saliva or mucus of an infected person, or through respiratory droplets from coughing or sneezing.

Therefore, standard and droplet precautions are sufficient to prevent transmission. Choice D is wrong because Koplik spots are a characteristic sign of measles, not rubella.

Koplik spots are small white spots that appear on the inside of the cheeks before the measles rash develops. Rubella causes a pink or red rash that usually starts on the face and moves down the body.

Normal ranges for rubella antibody tests are:

• IgM: Negative or less than 0.9 IU/mL
• IgG: Negative or less than 10 IU/mL

A positive IgM result indicates a recent or current infection, while a positive IgG result indicates a past infection or immunity from vaccination.

The nurse should hold the irrigation solution bottle with the label facing away from the palm of the hand. This prevents the label from becoming wet and unreadable, and also prevents contamination of the sterile solution by the hand.

Choice A is wrong because placing sterile gauze over areas of spilled solution within the sterile field does not restore sterility. Any spillage or moisture on the sterile field renders it contaminated and unusable.

Choice C is wrong because removing the cap and placing it sterile-side up on a clean surface does not maintain sterility. The cap should be placed on a sterile surface, such as a sterile towel, with the edges up to prevent contamination of the inside of the cap.

Choice D is wrong because holding the bottle in the center of the sterile field when pouring the solution increases the risk of contaminating the field with drips from the bottle. The bottle should be held at least 15 cm (6 in) above the field and at its edge when pouring.

This is the first action the nurse should take because it addresses the immediate need to prevent further infections and ensure patient safety. According to the CDC, catheter- associated urinary tract infections (CAUTIs) are the most common type of healthcare- associated infection (HAI) and are associated with increased morbidity, mortality, hospital cost, and length of stay. The major determinant for development of bacteriuria is duration of catheterization. Therefore, nursing staff should be trained on proper indications, insertion, maintenance, and removal of urinary catheters to reduce the risk of CAUTIs.

Choice B is wrong because meeting with providers to discuss measures to decrease the infections is not the first action the nurse should take.

While it is important to collaborate with providers on strategies to prevent CAUTIs, such as limiting the use of catheters and prescribing appropriate antibiotics, this is not an urgent priority compared to educating the nursing staff on infection control procedures.

Choice C is wrong because revising the current policy for catheter care is not the first action the nurse should take.

While it is important to review and update the policy based on current evidence and guidelines, this is not an immediate intervention that will prevent further infections.

The nurse should first ensure that the nursing staff are following the existing policy and provide feedback and education as needed.

Choice D is wrong because identifying possible precipitating factors related to the infections is not the first action the nurse should take.

While it is important to conduct a root cause analysis to identify and address the factors that contribute to CAUTIs, such as poor hand hygiene, inadequate sterile technique, or inappropriate catheter use, this is not a priority over educating the nursing staff on infection control procedures.

The nurse should first implement measures to prevent further infections and then investigate the causes of the problem.

Administer sublingual nitroglycerin.

Nitroglycerin is a vasodilator that can relieve chest pain caused by myocardial ischemia. The nurse should administer it as soon as possible to improve blood flow to the heart and reduce the risk of myocardial infarction. The nurse should also monitor the client’s blood pressure and heart rate after giving nitroglycerin, as it can cause hypotension and reflex tachycardia.

Choice A is wrong because checking a STAT cardiac troponin is not the first priority.

Cardiac troponin is a biomarker that indicates myocardial injury, but it may not rise until several hours after the onset of chest pain.

Therefore, it is not useful for immediate diagnosis or treatment of acute coronary syndrome. Choice B is wrong because requesting a prescription for a beta-blocker is not the first priority.

Beta-blockers are medications that can lower blood pressure and heart rate, and reduce the oxygen demand of the heart.

They can prevent or reduce the recurrence of chest pain and complications of acute coronary syndrome, but they are not indicated for immediate relief of chest pain.

Choice D is wrong because administering oxygen is not the first priority.

Oxygen therapy can increase the oxygen supply to the heart and reduce ischemia, but it is not necessary for all clients with chest pain.

Oxygen therapy should be based on the client’s oxygen saturation level and clinical condition.

If the client’s oxygen saturation is normal or high, oxygen therapy may not be beneficial and may even be harmful.

This is because potassium is a medication that can cause cardiac arrest if given too quickly or in high doses. A nurse who administers potassium via IV bolus is not providing the standard of care that a similarly trained nurse would have offered under the same circumstances. This could result in harm or death to the patient.

Choice A is wrong because placing a yellow bracelet on a client who is at risk for falls is not malpractice, but rather a safety measure.

A yellow bracelet indicates that the client needs assistance with mobility and should not be left alone. This is a common practice in many health care facilities to prevent falls and injuries.

Choice B is wrong because leaving a nasogastric tube clamped after administering oral medication is not malpractice, but rather a mistake.

A nasogastric tube is a tube that goes through the nose and into the stomach to deliver nutrition or medication.

It should be unclamped after giving oral medication to allow the medication to enter the stomach and prevent reflux or aspiration. However, this error does not rise to the level of malpractice unless it causes harm to the patient, such as vomiting, choking, or infection.

Choice D is wrong because documenting communication with a provider in the progress notes of the client’s medical record is not malpractice, but rather a good practice.

Exercise can help stimulate bowel movements and prevent constipation, which is a common side effect of opioid medications. Exercise can also improve blood circulation, reduce stress, and enhance mood, which can benefit clients who have chronic pain.

Choice A is wrong because decreasing insoluble fiber intake can worsen constipation. Insoluble fiber adds bulk to the stool and helps it pass more easily through the colon.

Clients who take opioid medications should increase their intake of insoluble fiber from sources such as whole grains, fruits, vegetables, nuts, and seeds.

Choice C is wrong because drinking less water can lead to dehydration and hardening of the stool, which can make it more difficult to pass.

Clients who take opioid medications should drink plenty of water to keep the stool soft and moist.

Choice D is wrong because taking a laxative every day can cause dependence, tolerance, and electrolyte imbalance.

Laxatives should be used only as a last resort and under the guidance of a health care provider.

Clients who take opioid medications should try other methods of preventing constipation first, such as increasing exercise, fiber, and water intake.

The nurse should ensure the state health department has been notified of the child’s Lyme disease, as it is a reportable disease in most states. Reporting helps to monitor the incidence and prevalence of Lyme disease and to implement prevention and control measures.

Choice B is wrong because antitoxin is not used to treat Lyme disease.

Antitoxin is a substance that neutralizes the effects of a toxin, such as botulism or tetanus. Lyme disease is caused by a bacterium called Borrelia burgdorferi, which can be treated with antibiotics.

Choice C is wrong because Lyme disease is not transmitted by sharing personal belongings. Lyme disease is spread to humans by the bite of infected ticks that carry the bacterium. The risk of getting Lyme disease can be reduced by avoiding tick-infested areas, wearing protective clothing, using insect repellent, and removing ticks promptly.

Choice D is wrong because skin necrosis is not a common complication of Lyme disease.

Skin necrosis is the death of skin tissue due to lack of blood supply or infection. Lyme disease can cause a characteristic skin rash called erythema migrans, which is usually circular or oval and expands over time. Other possible signs and symptoms of Lyme disease include fever, headache, fatigue, joint pain, and neurological problems.