The correct answer is choice D. Requires nasogastric suction.

Nasogastric suction removes gastric secretions that contain potassium, leading to a loss of potassium from the body.

This can cause hypokalemia, which is a low level of potassium in the blood.

Choice A is wrong because Addison’s disease causes hyperkalemia, which is a high level of potassium in the blood.

Choice B is wrong because tissue damage can release potassium from the cells into the blood, causing hyperkalemia.

Choice C is wrong because uric acid level is not related to potassium level.

Uric acid is a waste product of purine metabolism that can cause gout or kidney stones if elevated.

The nurse should include monitoring for muscle paralysis in the plan of care for a client with botulism poisoning. Botulism is a serious bacterial illness that can cause muscle paralysis and can be life threatening. Monitoring for muscle paralysis is essential for early detection and intervention.

Choice B is incorrect because contact isolation is not necessary for the treatment of botulism.

Choice C is incorrect because increased salivation is not a common symptom of botulism.

Choice D is incorrect because clindamycin hydrochloride is not used to treat botulism.

The correct answer is choice C, weigh the client before and after the treatment. The nurse should weigh the client before and after the treatment to evaluate the effectiveness of the dialysis, and determine whether the appropriate amount of fluid has been removed. Choice A is incorrect because the dialysate should be warmed prior to infusion, not chilled. Choice B is incorrect because sterile gloves, not clean gloves, are required when handling dialysate bags. Choice D is incorrect because diarrhea is not a common complication of peritoneal dialysis.

Choice A: Chilling the dialysate prior to infusion is incorrect because the dialysate should be warmed prior to infusion, not chilled.

Choice B: Using clean gloves when handling dialysate bags is incorrect because sterile gloves, not clean gloves, are required when handling dialysate bags.

Choice D: Monitoring the client for diarrhea is incorrect because diarrhea is not a common complication of peritoneal dialysis.

The correct answer is choice B, herpes zoster. A 65-year-old client should receive the herpes zoster vaccine, which is recommended for adults over the age of 60 years to prevent shingles. Choice A is incorrect because inactivated polio virus vaccine is recommended for travelers to areas where polio is endemic or epidemic, and for laboratory workers who handle specimens containing poliovirus. Choice C is incorrect because the human papillomavirus vaccine is recommended for females aged 9-26 years and males aged 9-21 years. Choice D is incorrect because the measles, mumps, and rubella vaccine is recommended for individuals born after 1957 who have not had the vaccine or the diseases.

Choice A: Inactivated polio virus vaccine is incorrect because it is recommended for travelers to areas where polio is endemic or epidemic, and for laboratory workers who handle specimens containing poliovirus.

Choice C: Human papillomavirus vaccine is incorrect because it is recommended for females aged 9-26 years and males aged 9-21 years.

Choice D: Measles, mumps, and rubella vaccine is incorrect because it is recommended for individuals born after 1957 who have not had the vaccine or the diseases.

The correct answer is choice B, a client who had abdominal surgery 2 days ago and the incision line is separating. This client requires immediate attention as a separating incision can indicate wound dehiscence or evisceration, which are surgical emergencies. Choice A is incorrect because although C. difficile is a serious infection, liquid stools are a common symptom and do not require immediate attention. Choice C is incorrect because intermittent coughing up clear sputum is a normal finding for a client with a tracheostomy, and does not indicate a change in the client's condition. Choice D is incorrect because the client fell 12 hours ago and reports pain as 4 on a scale of 0 to 10, which indicates a low level of pain.

Choice A: A client who has Clostridium difficile and has liquid stools is incorrect because although C. difficile is a serious infection, liquid stools are a common symptom and do not require immediate attention.

Choice C: A client who has a chronic tracheostomy and is intermittently coughing up clear sputum is incorrect because intermittent coughing up clear sputum is a normal finding for a client with a tracheostomy, and does not indicate a change in the client's condition.

Choice D: A client who fell 12 hours ago and reports pain as 4 on a scale of 0 to 10 is incorrect because the level of pain is low and does not require immediate attention.

The correct answer is choice D. The nurse should identify an oral temperature of 39°C (102.2°F) as the priority finding in a client who is postoperative following a total thyroidectomy for hyperthyroidism. An elevated temperature can indicate infection, which is a risk after surgery. The nurse should report this finding to the provider immediately.

Choices A, B, and C are incorrect because moderate amount of serosanguineous drainage on dressings, serum calcium level 9.2 mg/dL, and report of a sore throat, respectively, are expected findings after a total thyroidectomy and do not require immediate action.

The correct answer is choice A, participate in reminiscence therapy with the client. This is an effective intervention for individuals with Alzheimer's disease. It involves encouraging the client to discuss past experiences and events. It has been shown to improve mood, decrease agitation, and increase communication skills. The reminiscence therapy should be individualized and tailored to the client's interests and abilities.

1. Raising the four side rails on the client's bed is not the correct answer because this could cause harm to the client by restricting their mobility and independence.
2. Alternating the client's daily routine is not the correct answer because individuals with Alzheimer's disease benefit from a consistent routine, which helps them to feel more secure and less anxious.
3. Keeping the lights dimmed is not the correct answer because it can be disorienting and confusing for clients with Alzheimer's disease, who need adequate lighting to distinguish their surroundings.

The correct answer is choice A, apply a motion sensor mat to the client's bed. This is an effective intervention to monitor the client's movements and prevent falls. The mat is placed under the bed sheet and will sound an alarm if the client tries to get out of bed.

1. Moving the overbed table away from the bed is not the correct answer because it does not prevent falls.
2. Raising all four side rails while the client is in bed is not the correct answer because it can cause the client to feel trapped and can lead to injuries if they try to climb over the rails.
3. Leaving the television on in the client's room is not the correct answer because it can be distracting and interfere with the client's sleep.

A change in pupil size can indicate an increase in intracranial pressure, which can lead to a life-threatening situation. The nurse should immediately report this finding to the provider.

Choice B is incorrect because difficulty speaking is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.

Choice C is incorrect because inability to follow direction is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.

Choice D is incorrect because right-sided weakness is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.

Reasons why the other choices are not answers:

Choice B: Difficulty speaking is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.

Choice C: Inability to follow direction is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.

Choice D: Right-sided weakness is a common finding in clients who have had a left hemispheric stroke and should be monitored but is not an immediate concern.

This response indicates that the client understands that sudden jaw pain can be a sign of a heart attack and requires immediate medical attention.

A. "I will take four nitroglycerin sublingual tablets if I have chest pain." This is an incorrect statement because taking four nitroglycerin sublingual tablets can lead to hypotension and can be life-threatening.

B. "I will have hot, dry, and flushed skin if I am having a heart attack." This is an incorrect statement because hot, dry, and flushed skin is not a typical sign of a heart attack.

C. "I will wait 30 minutes before taking action if I have heartburn." This is an incorrect statement because heartburn is not a symptom of angina and waiting 30 minutes to take action can lead to further complications.

Explanation: The client with angina should be educated about the signs and symptoms of a heart attack and when to seek medical attention. Jaw pain is one of the signs of a heart attack, and the client should seek emergency medical attention immediately.

This ABG result indicates that the client has an excess of carbon dioxide (CO2) due to hypoventilation.

A. "Metabolic acidosis" is an incorrect answer because the pH is low and the HCO3 is within normal range.

C. "Respiratory alkalosis" is an incorrect answer because the pH is low and the PaCO2 is elevated.

D. "Metabolic alkalosis" is an incorrect answer because the HCO3 is within normal range, and the pH is low.

Explanation: The ABG result shows a low pH, elevated PaCO2, and normal HCO3, indicating respiratory acidosis. This condition can be caused by conditions that affect breathing, such as pneumonia, asthma, or chronic obstructive pulmonary disease (COPD).

The correct answer is choice B, which cleans a blood spill with chlorine bleach. This is an appropriate action for infection control because bleach is an effective disinfectant that can kill most pathogens, including bloodborne viruses such as HIV and hepatitis B and C.

A. Rolling soiled linen with the clean side in it before placing it in the laundry bag is not the correct answer because it can spread pathogens and cause cross-contamination.

Performing hand hygiene with hands at elbow level is not the correct answer because it is not the correct technique for hand hygiene, which involves washing hands with soap and water or using an alcohol-based hand sanitizer.

Instructing a female client to wipe the perineal area from back to front is not the correct answer because it can cause contamination of the urethra and increase the risk of urinary tract infections.

Ginkgo biloba is a herb that can interact with enoxaparin and increase the risk of bleeding, so the nurse should report its use to the provider. The other options, A (Echinacea), B (Flaxseed powder), and C (Probiotics) do not have any known interactions with enoxaparin, so they do not need to be reported to the provider.

Reasons, why the other choices are not answers, are:

A. Echinacea is a herb that is commonly used to boost the immune system and has not been found to interact with enoxaparin.

B. Flaxseed powder is a dietary supplement that is high in fiber and omega-3 fatty acids and has not been found to interact with enoxaparin.

C. Probiotics are live bacteria that can be found in certain foods or supplements, and they have not been found to interact with enoxaparin.

In summary, the nurse should report the use of Ginkgo biloba to the provider, as it can interact with enoxaparin and increase the risk of bleeding. Echinacea, Flaxseed powder, and Probiotics do not have any known interactions with enoxaparin, so they do not need to be reported to the provider.

Elevate the head of the client's bed for 1 hr after the feeding. This is because elevating the head of the client's bed to at least 30 degrees can help prevent aspiration and gastric reflux.

Choice B is incorrect because administering the feeding solution at a cold temperature can cause discomfort and diarrhea.

Choice C is incorrect because rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site.

Choice D is incorrect because flushing the tube with 90 mL of sterile water before and after the feeding is not necessary as long as the tube is adequately flushed before and after each feeding.

The explanation for why the other choices are not answered: B – Administering the feeding solution at a cold temperature can cause discomfort and diarrhea, so it should not be done. C – Rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site, so this is not the correct action. D – Flushing the tube with 90 mL of sterile water before and after the feeding is unnecessary to do as long as the tube is adequately flushed before and after each feeding. Thus, this is not the correct answer.

Epoetin alfa is a medication used to stimulate erythropoiesis, the production of red blood cells. An increase in the client's hemoglobin level indicates that the medication has been effective. The normal range of hemoglobin for adult females is 12-16 g/dL and for adult males is 13.5-17.5 g/dL. A hemoglobin level of 11 g/dL is slightly below the normal range, but it is an improvement from a lower level. Choice B, WBC count 9,000/mm3 is unrelated to the medication and is within the normal range. Choice

C, total calcium 10 mg/dL, and choice D, PT 12 seconds, are also unrelated to the medication and are within the normal range.

Choice B (WBC count 9,000/mm3) is not an answer because it is unrelated to the medication and is within the normal range.

Choice C (total calcium 10 mg/dL) is not an answer because it is unrelated to the medication and is within the normal range.

Choice D (PT 12 seconds) is not an answer because it is unrelated to the medication and is within the normal range.

The correct answer is Choice D.

Choice A rationale: Closing the door to the client’s room would help to contain the fire and prevent it from spreading to other areas. However, this should not be the nurse’s first action. The nurse’s primary responsibility is to ensure the safety of the client. Therefore, removing the client from the room should be the first action taken.

Choice B rationale: Obtaining a fire extinguisher is an important step in responding to a fire. However, it should not be the first action taken by the nurse. The nurse’s primary responsibility is to ensure the safety of the client. Therefore, removing the client from the room should be the first action taken.

Choice C rationale: Pulling the fire alarm panel is an important step in alerting others in the facility about the fire. However, it should not be the first action taken by the nurse. The nurse’s primary responsibility is to ensure the safety of the client. Therefore, removing the client from the room should be the first action taken.

Choice D rationale: The nurse’s primary responsibility is to ensure the safety of the client. If there is a fire in the client’s room, the nurse should first remove the client from the room to ensure their safety. Once the client is safe, the nurse can then take further actions to respond to the fire, such as pulling the fire alarm panel, closing the door to the room, and obtaining a fire extinguisher.

The nurse should perform neurovascular checks of the affected extremity every 2 hours to monitor for any signs of compartment syndrome or impaired circulation. It is important to assess for the five Ps: pain, pulse, pallor, paresthesia, and paralysis. Using a hair dryer to relieve itching can cause burns and is not a recommended intervention. Positioning the fractured arm below the level of the client's heart can increase swelling and exacerbate pain. Immobilizing the client's fingers using a hand splint is not indicated unless there is a finger fracture or injury.

Choice A (Use a hair dryer to blow hot air into the cast to relieve itching) is not an answer because it can cause burns and is not a recommended intervention.

Choice C (Position the fractured arm below the level of the client's heart) is not an answer because it can increase swelling and exacerbate pain.

Choice D (Immobilize the client's fingers using a hand splint) is not an answer because it is not indicated unless there is a finger fracture or injury.

The correct answer is choice D, "I should adjust the TENS unit until I feel a tingling sensation." This is an appropriate statement that indicates the client understands how to use the TENS unit. The TENS unit works by sending electrical impulses to the nerves to block pain signals. The client should adjust the unit until they feel a tingling sensation, which is the desired effect.

"The TENS unit administers a continuous dose of pain medication" is not the correct answer because the TENS unit does not administer medication.

"I will need to charge the TENS unit for 2 hours each day" is not the correct answer because the TENS unit is battery operated and does not need to be charged.

"The TENS unit should be applied at least 6 inches from the actual site of my pain" is not the correct answer because the electrodes should be placed directly on the site of the pain.

Opioid toxicity causes central nervous system and respiratory depression, which can lead to low blood pressure or hypotension.

Choice A. Diaphoresis is not correct because opioid toxicity does not cause excessive sweating. Diaphoresis can be a sign of opioid withdrawal or other conditions.

Choice B. Pupillary dilation is not correct because opioid toxicity causes miosis or pinpoint pupils due to the stimulation of the parasympathetic nervous system .

Choice C. Chest pain is not correct because opioid toxicity does not cause chest pain. Chest pain can be a sign of cardiac ischemia, pulmonary embolism, or other serious conditions.

The correct answer is choice B, Offer oral fluids every 4 hr. To correct dehydration, the nurse should encourage the client to drink fluids orally as tolerated. Offering oral fluids every 4 hr helps the client stay hydrated, which reduces the risk of complications. Choice A is incorrect because neck vein distention is not related to dehydration. Choice C is incorrect because monitoring pulse pressure is not a common intervention for treating dehydration. Choice D is incorrect because limiting oral fluids before bedtime is not recommended when the client is dehydrated.

Other choices:

A. Check for neck vein distention: Neck vein distention is not a common intervention for treating dehydration.

Monitor pulse pressure every 6 hr: Monitoring pulse pressure is not a common intervention for treating dehydration.

Limit oral fluids prior to bedtime: Limiting oral fluids before bedtime is not recommended when the client is dehydrated.

The client should wear a mask during transport to prevent the spread of infectious droplets. The nurse should wear appropriate personal protective equipment (PPE) based on the precautions required for the specific client, which in this case would be a mask. The nurse does not need to wear a gown as droplet precautions do not require the use of a gown during transport.

Option A is incorrect because wearing a gown during transport is not necessary for droplet precautions.

Option B is incorrect because the nurse should wear a mask during transport, not the client.

Option D is incorrect because wearing a gown during transport is not necessary for droplet precautions.

"I will try to maintain my blood pressure around 116/72." This is because maintaining blood pressure within a normal range can help prevent heart disease. Choice A is incorrect because increasing dairy intake can lead to a higher intake of saturated fats which can increase the risk of heartdisease.

Choice B is incorrect because lowering, not raising, LDL cholesterol is essential in preventing heart disease.

Choice C is incorrect because exercising only twice a week for 25 minutes is not enough to prevent heart disease.

An explanation for why the other choices are not answers: A – Increasing dairy intake can lead to a higher intake of saturated fats which can increase the risk of heart disease, so this is not the correct statement. B – Lowering, not raising, LDL cholesterol is essential in preventing heart disease, so this is not the correct statement. C – Exercising only twice a week for 25 minutes is not enough to prevent heart disease. Thus, this is not the correct statement.

The correct answer is choice A, Perform suctioning. Restlessness and crackles in the lungs may indicate respiratory distress or airway obstruction, which may be due to mucus or secretions blocking the tracheostomy tube. Performing suctioning helps clear the airway of secretions, which will improve the client's breathing. Choice B is incorrect because instilling saline into the tubing is not a common intervention for managing restlessness and crackles. Choice C is incorrect because checking the cuff pressure is not related to managing restlessness and crackles. Choice D is incorrect because increasing humidification is not a common intervention for managing restlessness and crackles.

Other choices:

Instill saline into the tubing: Instilling saline into the tubing is not a common intervention for managing restlessness and crackles.

Check the cuff pressure: Checking the cuff pressure is not related to managing restlessness and crackles.

Increase the humidification: Increasing humidification is not a common intervention for managing restlessness and crackles.

Palpable area of induration, greater than 10 mm (0.4 in) in diameter. This indicates a positive tuberculin skin test (TST) reaction for a person with no known risk factors for TB infection. A positive TST reaction means that the person has been infected with Mycobacterium tuberculosis, the bacterium that causes TB disease, and needs further testing to confirm the diagnosis and rule out active TB disease.

The other choices are not correct because:

- Choice A. Nonpalpable area of redness, less than 5 mm (0.2 in) in diameter. This indicates a negative TST reaction for any person, regardless of their risk factors for TB infection. A negative TST reaction means that the person has not been infected with Mycobacterium tuberculosis or has a very low level of immune response to the bacterium.

- Choice B. Area of ecchymosis, greater than 12 mm (0.5 in) in diameter. This indicates a bruise or bleeding under the skin, not a TST reaction. Ecchymosis is not caused by the injection of tuberculin purified protein derivative (PPD) into the skin, but by trauma or injury to the blood vessels.

- Choice C. Tenderness at the injection site. This indicates a mild local reaction to the injection of tuberculin PPD into the skin, not a TST reaction. Tenderness is not measured in millimeters of induration (firm swelling), which is the standard way of reading TST results.

This finding could indicate the presence of bile leakage, which can occur following a cholecystectomy. The provider should be notified immediately as the client may require further interventions. Incisional pain, shoulder pain, and a dry and intact abdominal dressing are expected findings in the postoperative period.

Choice A, reporting of shoulder pain, is not the correct answer because this is a common finding post-cholecystectomy, which is often due to the presence of carbon dioxide used during the surgical procedure.

Choice C, incisional pain 5 out of 10 on a pain scale, is not the correct answer because this level of pain is within the expected range for the postoperative period.

Choice D, abdominal dressing dry and intact, is not the correct answer because this is an expected finding in the postoperative period.