Include the date and time of the assessment.

Rationale: The nurse should include the date and time of the wound assessment in the documentation, as this provides a chronological and accurate record of the client's condition and response to treatment.

Incorrect options:

B) Use abbreviations that are approved by the facility. - This is a partially correct statement, as the nurse should use abbreviations that are approved by the facility to ensure clarity and consistency in the documentation. However, this is not the best answer, as some abbreviations may still be confusing or ambiguous, and should be avoided or spelled out.

C) Copy and paste the previous assessment as a template. - This is an incorrect statement, as copying and pasting the previous assessment as a template can result in errors, omissions, or duplication of information, compromising the quality and integrity of the documentation.

D) Delete any inaccurate entries made by other staff members. - This is an incorrect statement, as deleting any entries made by other staff members is unethical and illegal, as it alters the original record and may affect the client's care or legal outcomes. The nurse should follow the facility's policy on correcting errors in documentation, which usually involves drawing a single line through the error, writing "error" above it, and signing and dating it.

The client's blood pressure is 180/100 mm Hg and heart rate is 110 beats/min.

Rationale: The nurse should report the client's blood pressure and heart rate to the provider immediately, as these are signs of hypertensive crisis and tachycardia, which can indicate a serious cardiovascular complication, such as myocardial infarction, stroke, or heart failure.

Incorrect options:

A) The client has a history of hypertension and diabetes mellitus. - This is an important information to obtain from the client, as it indicates risk factors for cardiovascular disease. However, this is not an urgent finding that requires immediate reporting to the provider, as it does not reflect the client's current condition or acuity.

B) The client takes aspirin 81 mg daily and metformin 500 mg twice daily. - This is an important information to obtain from the client, as it indicates the medications that the client is taking for their chronic conditions. However, this is not an urgent finding that requires immediate reporting to the provider, as it does not reflect any adverse effects or interactions of these medications.

D) The client's chest pain radiates to the left arm and is relieved by nitroglycerin. - This is an important information to obtain from the client, as it indicates that the client has angina pectoris, which is chest pain caused by reduced blood flow to the heart muscle. However, this is not an urgent finding that requires immediate reporting to the provider, as it shows that the chest pain is stable and responsive to nitroglycerin.

Potassium 5.5 mEq/L

Rationale: The nurse should report the potassium level of 5.5 mEq/L to the provider before proceeding with

the blood transfusion, as this indicates hyperkalemia, which can cause cardiac arrhythmias or arrest. Blood transfusion can increase potassium levels further, especially if the blood has been stored for a long time or if it is administered rapidly.

Incorrect options:

A) Hemoglobin 8 g/dL - This is a low hemoglobin level, which indicates anemia, but it is not a contraindication for blood transfusion. In fact, blood transfusion may be indicated to treat severe anemia and improve oxygen delivery to the tissues.

B) Platelets 150,000/mm3 - This is a normal platelet count, which indicates adequate clotting function. It is not a reason to withhold or delay blood transfusion.

D) Blood type AB positive - This is the client's blood type, which is compatible with any blood type for transfusion, as AB positive is the universal recipient. It is not a reason to report to the provider or stop the transfusion.

Check the tubing for any leaks or kinks.

Rationale: The nurse should check the tubing for any leaks or kinks, as continuous bubbling in the water seal chamber indicates an air leak in the system, which can impair lung re-expansion and drainage. The nurse should locate and seal the leak, and notify the provider if necessary.

Incorrect options:

A) Clamp the chest tube near the insertion site. - This is an incorrect action, as clamping the chest tube can cause a tension pneumothorax, which is a life-threatening condition that occurs when air accumulates in the pleural space and compresses the lung and other structures. The nurse should only clamp the chest tube briefly when changing the drainage system or assessing for an air leak.

C) Increase the suction pressure to the drainage system. - This is an incorrect action, as increasing the suction pressure to the drainage system can cause damage to the lung tissue and increase the risk of infection. The nurse should follow

the provider's prescription and the manufacturer's guidelines for setting and adjusting the suction pressure.

D) Document the finding as an expected outcome. - This is an incorrect action, as documenting the finding as an expected outcome implies that continuous bubbling in the water seal chamber is normal, which it is not. The nurse should document

the finding as an abnormal finding and report it to the provider.

"Wash your hands with warm water and soap before testing."

Rationale: The nurse should instruct the client to wash their hands with warm water and soap before testing, as this helps to prevent infection and remove any substances that may interfere with the accuracy of the test result.

Incorrect options:

B) "Use alcohol wipes to clean your finger before pricking it." - This is an incorrect instruction, as using alcohol wipes to clean the finger can dry out and irritate the skin, and may also affect the test result if the alcohol is not completely dry before pricking.

C) "Squeeze your finger firmly to obtain a drop of blood." - This is an incorrect instruction, as squeezing the finger firmly can cause hemolysis or dilution of the blood sample, leading to inaccurate readings. The client should apply gentle pressure to the finger after pricking it.

D) "Choose a different finger for each test throughout the day." - This is an incorrect instruction, as choosing a different finger for each test throughout the day can increase the risk of infection and pain. The client should rotate the testing sites within one finger or use alternate sites, such as the forearm or palm.

The presence and quality of pedal pulses on both legs.

Rationale: The nurse should obtain information on the presence and quality of pedal pulses on both legs from the report, as this indicates the adequacy of blood circulation and perfusion to the lower extremities, which can be compromised by surgery, positioning, or complications such as thromboembolism or compartment syndrome.

Incorrect options:

A) The type and size of the prosthesis used may be important information for the surgical team and the client's medical record, but it is not immediately relevant to the immediate post-operative care provided by the nurse.

B) The amount and color of urine output during surgery is not directly related to the client's condition after a total hip arthroplasty and is not the primary focus of the nurse's assessment at this time.

C) The type and dose of anesthesia administered is important information for the client's medical record and may have implications for post-operative care, but it is not the most critical information for the nurse to obtain immediately upon receiving the report.