Choice A reason: Platelet count is not directly related to wound infection. Platelets are involved in blood clotting and hemostasis. A low platelet count can increase the risk of bleeding, while a high platelet count can indicate inflammation or malignancy.

Choice B reason: Serum albumin is a measure of protein status and nutritional status. A low serum albumin can indicate malnutrition, liver disease, kidney disease, or fluid imbalance. A high serum albumin can indicate dehydration or chronic infection. Serum albumin is not a specific indicator of wound infection.

Choice C reason: Neutrophil count is a measure of the body's immune response to infection. Neutrophils are the most abundant type of white blood cells and are the first line of defense against bacterial infections. A high neutrophil count can indicate an acute infection, while a low neutrophil count can indicate a weakened immune system or a chronic infection. Neutrophil count is the most relevant laboratory value to evaluate wound infection.

Choice D reason: Blood pH level is a measure of the body's acid-base balance. A normal blood pH level is between 7.35 and 7.45. A low blood pH level can indicate acidosis, while a high blood pH level can indicate alkalosis. Blood pH level can be affected by many factors, such as respiratory function, metabolic function, renal function, and medication use. Blood pH level is not a specific indicator of wound infection.

Choice A reason: Teaching the client breathing exercises can help improve lung function, reduce mucus accumulation, and prevent atelectasis and pneumonia. Breathing exercises can include pursed-lip breathing, diaphragmatic breathing, and coughing techniques.

Choice B reason: Establishing a regular bladder routine is not directly related to pulmonary complications. However, it can help prevent urinary tract infections, bladder distension, and incontinence, which are common problems for clients with ALS.

Choice C reason: Performing chest physiotherapy can help mobilize secretions, improve ventilation, and prevent respiratory infections. Chest physiotherapy can include percussion, vibration, and postural drainage.

Choice D reason: Encouraging use of incentive spirometer can help increase lung expansion, improve oxygenation, and prevent alveolar collapse. Incentive spirometer is a device that measures the amount of air the client can inhale and exhale.

Choice E reason: Initiating passive range of motion exercises can help maintain joint mobility, prevent contractures, and improve circulation. Passive range of motion exercises are performed by the nurse or a caregiver who moves the client's limbs through their full range of motion.

Choice A reason: Joint pain is a common symptom of SLE, which is an autoimmune disease that causes inflammation and damage to various organs and tissues. Joint pain can be managed with anti-inflammatory drugs, analgesics, and corticosteroids. Joint pain is not a life-threatening finding that requires immediate attention from the health care provider.

Choice B reason: Hematuria is the presence of blood in the urine, which can indicate kidney damage or failure. Kidney involvement is one of the most serious complications of SLE, which can lead to end-stage renal disease and require dialysis or transplantation. Hematuria is a critical finding that requires prompt intervention and treatment from the health care provider.

Choice C reason: Low grade fever is another common symptom of SLE, which can be caused by infection, inflammation, or medication side effects. Low grade fever can be treated with antipyretics, fluids, and antibiotics if needed. Low grade fever is not a life-threatening finding that requires immediate attention from the health care provider.

Choice D reason: Muscle atrophy is the loss of muscle mass and strength, which can occur due to inactivity, malnutrition, or steroid use. Muscle atrophy can be prevented or reversed with exercise, nutrition, and physiotherapy. Muscle atrophy is not a life-threatening finding that requires immediate attention from the health care provider.

Choice A reason: Varicella is another name for chickenpox, which is caused by the varicella-zoster virus. Herpes zoster, also known as shingles, is a reactivation of the same virus that causes a painful rash along a nerve pathway. People who have had chickenpox are at risk of developing shingles later in life, especially if their immune system is weakened. Asking the client if everyone at home has already had varicella can help the nurse determine the risk of transmission and the need for isolation precautions.

Choice B reason: Antifungal creams are not effective for herpes zoster, which is caused by a virus, not a fungus. Antifungal creams are used to treat fungal infections, such as athlete's foot, ringworm, or candidiasis. Asking the client if the antifungal creams have been effective is not relevant to the condition and can indicate a lack of knowledge or a misdiagnosis.

Choice C reason: Dry patches on the feet and hands are not typical signs of herpes zoster, which usually causes a blistering rash along a nerve pathway. Dry patches on the feet and hands can be caused by other conditions, such as eczema, psoriasis, or diabetes. Asking the client if they have any dry patches on their feet and hands is not helpful to assess the condition and can divert the attention from the main problem.

Choice D reason: Sharing combs and brushes is not a common mode of transmission for herpes zoster, which is spread by direct contact with the fluid from the blisters. Sharing combs and brushes can transmit other infections, such as lice, scabies, or impetigo. Asking the client if their family members share combs and brushes is not pertinent to the condition and can imply a poor hygiene or a stigma.

Choice A reason: Beginning a weight loss program can help reduce the severity of OSA, which is a condition that causes repeated episodes of breathing cessation during sleep due to upper airway obstruction. Excess weight can contribute to OSA by increasing the fat deposits around the neck and throat, which can narrow the airway and make it more prone to collapse. Losing weight can help improve the airflow and reduce the need for CPAP therapy.

Choice B reason: Drinking 1 to 2 glasses of wine at bedtime can worsen OSA, which is a condition that requires adequate oxygenation and ventilation during sleep. Alcohol can relax the muscles of the throat and tongue, which can increase the risk of airway obstruction and apnea. Alcohol can also disrupt the sleep cycle and quality, which can affect the overall health and well-being of the client.

Choice C reason: Taking sedatives prior to sleep can also worsen OSA, which is a condition that requires alertness and arousal during sleep to resume breathing after an apneic episode. Sedatives can depress the central nervous system and the respiratory drive, which can reduce the responsiveness and the ability to overcome the airway obstruction. Sedatives can also have adverse effects, such as drowsiness, confusion, and dependency.

Choice D reason: Sleeping with the head of the bed flat can also worsen OSA, which is a condition that requires optimal positioning and alignment during sleep to prevent the airway obstruction. Sleeping with the head of the bed flat can cause the tongue and the soft palate to fall back and block the airway, especially when lying on the back. Sleeping with the head of the bed elevated can help open the airway and reduce the snoring and the apnea.

Choice A reason: Rheumatoid factor is an antibody that is produced by the immune system and can bind to normal tissues, causing inflammation and damage. Rheumatoid factor is a marker of the autoimmune disease process that underlies rheumatoid arthritis, which is a chronic condition that affects the joints and other organs. A high level of rheumatoid factor can confirm the diagnosis of rheumatoid arthritis and indicate the severity of the disease.

Choice B reason: Rheumatoid factor is not a specific indicator of kidney involvement in rheumatoid arthritis, which is a rare but possible complication of the disease. Kidney damage can occur due to inflammation of the blood vessels, medication side effects, or dehydration. Kidney function can be assessed by other laboratory tests, such as blood urea nitrogen, creatinine, and urine analysis.

Choice C reason: Rheumatoid factor is not a direct cause of joint degeneration in rheumatoid arthritis, which is a progressive condition that leads to joint deformity and disability. Joint degeneration can occur due to chronic inflammation, erosion of cartilage and bone, and formation of nodules and cysts. Joint damage can be evaluated by physical examination, x-rays, and magnetic resonance imaging.

Choice D reason: Rheumatoid factor is not a reliable predictor of the client’s condition in rheumatoid arthritis, which is a variable and unpredictable disease that can have periods of remission and exacerbation. The client’s condition can be influenced by many factors, such as age, gender, genetics, lifestyle, and treatment. The client’s condition can be monitored by clinical symptoms, functional status, and quality of life.

Choice A reason: Demonstrating the use of visual scanning during meals can help the client overcome the difficulty with visual perception, which is a common problem after a CVA. Visual perception is the ability to interpret and process the information received from the eyes. A CVA can damage the parts of the brain that are responsible for visual perception, causing impairments such as hemianopia, neglect, or agnosia. Visual scanning is a technique that involves moving the eyes or the head from side to side to scan the entire visual field and compensate for the missing or distorted information. Visual scanning can help the client see all the food on the tray and eat more adequately.

Choice B reason: Explaining that weight loss will be reversed after the acute phase of the stroke has ended is not a helpful response to the family's concern, as it does not address the current issue of the client's nutritional status. Weight loss is a common complication of CVA, due to factors such as dysphagia, anorexia, depression, or medication side effects. Weight loss can affect the client's recovery, immunity, and quality of life. Weight loss may or may not be reversed after the acute phase of the stroke, depending on the client's condition, treatment, and rehabilitation.

Choice C reason: Suggesting that the family bring foods from home that the client enjoys eating is not a sufficient response to the family's concern, as it does not address the underlying cause of the client's poor intake. The client's difficulty with visual perception may prevent her from seeing or recognizing the food, regardless of whether it is from the hospital or from home. The family should also consider the client's dietary restrictions, allergies, and preferences before bringing any food from home.

Choice D reason: Encouraging the family to offer to feed the client when she does not eat her entire meal is not an appropriate response to the family's concern, as it may undermine the client's autonomy and dignity. The client's difficulty with visual perception may not affect her ability to feed herself, as long as she can see the food and the utensils. The family should respect the client's independence and self-care, and only assist her when necessary. The family should also avoid forcing or coaxing the client to eat more than she wants, as this may cause discomfort or resentment.

Choice A reason: Wearing clothing to cover the radiation site is a correct action, as it can protect the skin from sun exposure, irritation, and infection. The clothing should be loose-fitting, soft, and made of natural fibers, such as cotton or linen. The clothing should also be changed daily and washed separately from other clothes.

Choice B reason: Washing the radiation site with antibacterial soap and water is an incorrect action, as it can dry out, damage, or inflame the skin. The skin in the radiation site is more sensitive and vulnerable to injury and infection. The client should use mild, unscented soap and water to gently cleanse the area once a day, and avoid rubbing or scrubbing the skin.

Choice C reason: Applying prescribed lotions to the radiation site is a correct action, as it can moisturize, soothe, and heal the skin. The client should use only the lotions that are recommended by the health care provider, and avoid any products that contain alcohol, perfume, or other irritants. The client should also apply the lotions at least one hour before or after the radiation treatment, and not during the treatment.

Choice D reason: Drying the area with patting motions after taking a shower is a correct action, as it can prevent friction and trauma to the skin. The client should use a soft, clean towel to gently pat the skin dry, and avoid rubbing or pulling the skin. The client should also avoid using hair dryers, heating pads, or ice packs on the radiation site.

Choice A reason: Inserting a nasogastric tube (NGT) and attaching to low intermittent suction is the priority intervention for a client with peptic ulcer disease who is vomiting and experiencing epigastric pain and nausea. This can help decompress the stomach, remove gastric contents, prevent further bleeding, and relieve the symptoms. The NGT should be inserted carefully and checked for proper placement before suctioning.

Choice B reason: Giving a prescribed analgesic for temperature above 101°F (38.3° C) is not the first intervention for a client with peptic ulcer disease who is vomiting and experiencing epigastric pain and nausea. Temperature elevation can indicate infection or inflammation, which can be treated with antibiotics or anti-inflammatory drugs. However, analgesics can have adverse effects on the gastrointestinal tract, such as irritation, ulceration, or bleeding. Analgesics should be given cautiously and after the cause of the fever is identified.

Choice C reason: Placing an indwelling urinary catheter and attaching a bedside drainage unit is not the first intervention for a client with peptic ulcer disease who is vomiting and experiencing epigastric pain and nausea. Urinary catheterization can help monitor the fluid balance, renal function, and blood loss of the client, but it is not a priority in this situation. Urinary catheterization can also pose risks of infection, trauma, or obstruction, and should be avoided unless necessary.

Choice D reason: Sending the client to x-ray for a flat plate of the abdomen is not the first intervention for a client with peptic ulcer disease who is vomiting and experiencing epigastric pain and nausea. X-ray can help diagnose the location and extent of the ulcer, perforation, or obstruction, but it is not a priority in this situation. X-ray can also expose the client to radiation, which can be harmful, and should be done only after the client is stabilized.

Choice A reason: Using incentive spirometer is not a relevant instruction for a client with BPH who underwent TUNA. Incentive spirometer is a device that helps improve lung function and prevent respiratory complications after surgery or prolonged bed rest. TUNA is a minimally invasive procedure that uses radiofrequency energy to shrink the prostate tissue and relieve the urinary obstruction. TUNA does not affect the respiratory system or require general anesthesia.

Choice B reason: Monitoring urinary stream for decrease in output is an important instruction for a client with BPH who underwent TUNA. Urinary output can reflect the kidney function and the effectiveness of the procedure. A decrease in urinary output can indicate urinary retention, infection, or bleeding, which are potential complications of TUNA. The client should report any changes in the urinary stream, such as difficulty, pain, frequency, urgency, or hesitancy, to the health care provider.

Choice C reason: Reporting when hematuria becomes pink tinged is not a necessary instruction for a client with BPH who underwent TUNA. Hematuria is the presence of blood in the urine, which is a common and expected finding after TUNA. Hematuria usually resolves within a few days and does not require intervention, unless it is excessive or persistent. The client should drink plenty of fluids to flush out the blood and prevent clot formation. The client should report any signs of infection, such as fever, chills, or foul-smelling urine, to the health care provider.

Choice D reason: Restricting physical activities is a correct instruction for a client with BPH who underwent TUNA. Physical activities can increase the blood pressure and the risk of bleeding or injury to the prostate. The client should avoid strenuous activities, such as lifting, running, or biking, for at least two weeks after the procedure. The client should also avoid sexual intercourse, driving, or sitting for long periods until the symptoms subside. The client should follow the health care provider's advice on when to resume normal activities.

Choice A reason: Cleaning the tongue and mouth with swabs is not the best initial nursing action, as it can cause more irritation and pain to the mucous membranes. Swabs can be abrasive and harsh on the inflamed and ulcerated tissues. The client should use a soft toothbrush or a sponge to gently clean the tongue and mouth, and avoid alcohol-based mouthwashes or rinses.

Choice B reason: Administering a topical analgesic per protocol is the best initial nursing action, as it can provide immediate relief and comfort to the client. Topical analgesics can numb the nerve endings and reduce the sensation of pain in the tongue and mouth. The client should follow the health care provider's instructions on how to apply the analgesic, and avoid eating or drinking for at least 30 minutes after the application.

Choice C reason: Obtaining a soft diet for the client is a correct nursing action, but not the best initial one, as it can help prevent further trauma and damage to the mucous membranes. A soft diet consists of foods that are easy to chew and swallow, such as soups, puddings, yogurts, and mashed potatoes. The client should avoid foods that are spicy, acidic, salty, or hard, such as citrus fruits, tomatoes, chips, and nuts.

Choice D reason: Encouraging frequent mouth care is a correct nursing action, but not the best initial one, as it can help prevent infection and promote healing of the mucous membranes. Frequent mouth care involves rinsing the mouth with water or saline solution several times a day, especially after meals and before bedtime. The client should also keep the lips moist with a lip balm or petroleum jelly.

Choice A reason: Using incentive spirometer is not a relevant instruction for a client with BPH who underwent TUNA. Incentive spirometer is a device that helps improve lung function and prevent respiratory complications after surgery or prolonged bed rest. TUNA is a minimally invasive procedure that uses radiofrequency energy to shrink the prostate tissue and relieve the urinary obstruction. TUNA does not affect the respiratory system or require general anesthesia.

Choice B reason: Monitoring urinary stream for decrease in output is an important instruction for a client with BPH who underwent TUNA. Urinary output can reflect the kidney function and the effectiveness of the procedure. A decrease in urinary output can indicate urinary retention, infection, or bleeding, which are potential complications of TUNA. The client should report any changes in the urinary stream, such as difficulty, pain, frequency, urgency, or hesitancy, to the health care provider.

Choice C reason: Reporting when hematuria becomes pink tinged is not a necessary instruction for a client with BPH who underwent TUNA. Hematuria is the presence of blood in the urine, which is a common and expected finding after TUNA. Hematuria usually resolves within a few days and does not require intervention, unless it is excessive or persistent. The client should drink plenty of fluids to flush out the blood and prevent clot formation. The client should report any signs of infection, such as fever, chills, or foul-smelling urine, to the health care provider.

Choice D reason: Restricting physical activities is a correct instruction for a client with BPH who underwent TUNA. Physical activities can increase the blood pressure and the risk of bleeding or injury to the prostate. The client should avoid strenuous activities, such as lifting, running, or biking, for at least two weeks after the procedure. The client should also avoid sexual intercourse, driving, or sitting for long periods until the symptoms subside. The client should follow the health care provider's advice on when to resume normal activities.

Choice A reason: Log rolling the client and placing adult disposable briefs beneath the client is not a correct intervention, as it can cause displacement or misalignment of the fracture, which can lead to complications, such as delayed healing, nerve damage, or infection. Log rolling is a technique that involves moving the client as a unit, without twisting or bending the spine. Adult disposable briefs are absorbent pads that can be worn to manage urinary incontinence.

Choice B reason: Maintaining traction while the client uses a urinal is the correct intervention, as it can prevent the disruption of the fracture stabilization and allow the client to void comfortably and safely. Traction is a force that is applied to the fractured bone to reduce, align, and immobilize it. A urinal is a container that can be used to collect urine from the client, without requiring the client to get out of bed or change position.

Choice C reason: Releasing the traction so the client can use a bedpan is not a correct intervention, as it can compromise the fracture reduction and alignment, and cause pain and discomfort to the client. A bedpan is a shallow vessel that can be used to collect urine or feces from the client, by placing it under the client's buttocks. Releasing the traction can also increase the risk of bleeding, swelling, or infection.

Choice D reason: Inserting an indwelling urinary catheter preoperatively is not a necessary intervention, unless the client has urinary retention, obstruction, or infection. An indwelling urinary catheter is a tube that is inserted into the bladder through the urethra, and attached to a drainage bag. An indwelling urinary catheter can pose risks of trauma, infection, or bladder spasms, and should be avoided unless indicated.

Choice A reason: A husky voice and complaints of hoarseness are not related to Cushing's syndrome, but may indicate a thyroid disorder or vocal cord damage.

Choice B reason: Warm, soft, moist, salmon-colored skin is not a characteristic of Cushing's syndrome, but may be seen in hyperthyroidism or infection.

Choice C reason: Visible swelling of the neck, with no pain, is not a sign of Cushing's syndrome, but may indicate a goiter or thyroid enlargement.

Choice D reason: Central-type obesity, with thin extremities, is a common feature of Cushing's syndrome, which is caused by excess cortisol production or exposure. Cortisol causes fat redistribution to the trunk, face, and back of the neck, while causing muscle wasting and weakness in the arms and legs.

Choice A reason: Explaining the specific reason for urgent notification is important, but it is not the first information that the nurse should provide. The nurse should first identify the client and the situation, then provide the background, assessment, and recommendation.

Choice B reason: Obtaining a PRN prescription for acetaminophen for fever over 101° F (38.3° C) is a possible recommendation that the nurse can make, but it is not the first information that the nurse should provide. The nurse should first identify the client and the situation, then provide the background, assessment, and recommendation.

Choice C reason: Prefacing the report by stating the client’s name and admitting diagnosis is the first information that the nurse should provide, according to the SBAR communication process. This helps to establish the identity and context of the client and the situation.

Choice D reason: Communicating the pre-transfusion temperatures is part of the assessment that the nurse should provide, but it is not the first information that the nurse should provide. The nurse should first identify the client and the situation, then provide the background, assessment, and recommendation.

Choice A reason: Providing the first medication prescribed for pain management is the best intervention that the nurse can implement first, because it can prevent the escalation of pain and reduce the need for higher doses later. The nurse should follow the principles of pain management, such as administering analgesics before pain becomes severe, using a multimodal approach, and individualizing the plan of care.

Choice B reason: Reviewing medical records to obtain pain tolerance expectations is not a priority intervention that the nurse should implement first, because it may not reflect the current pain level or needs of the client. Pain tolerance is influenced by many factors, such as culture, age, gender, and previous experiences, and it may vary from person to person and from situation to situation.

Choice C reason: Waiting until the client is awake before providing pain management is not a recommended intervention that the nurse should implement first, because it can lead to inadequate pain relief and delayed recovery. The nurse should not assume that the client is not in pain because of sedation, but should use other indicators, such as vital signs, facial expressions, and body movements, to assess pain.

Choice D reason: Attempting to obtain a self-report of pain level from the client is not a feasible intervention that the nurse should implement first, because the client may not be able to respond due to sedation. The nurse should use a valid and reliable pain assessment tool that is appropriate for the client's condition, such as the Behavioral Pain Scale (BPS) or the Critical-Care Pain Observation Tool (CPOT), to measure pain.

Choice A reason: Exposure to persons with pneumonia or chickenpox is not a good idea for anyone, but it is not the main factor that can worsen COPD. COPD is a chronic inflammatory condition that affects the airways and the lungs, and it is mainly caused by smoking or other environmental irritants. Pneumonia and chickenpox are acute infections that can affect the respiratory system, but they are not the primary cause of COPD exacerbation.

Choice B reason: Excessive physical exertion and respiratory tract infections are the most common triggers that can lead to COPD exacerbation, which is a sudden worsening of symptoms, such as shortness of breath, cough, and mucus production. Physical exertion can increase the oxygen demand and the work of breathing, while respiratory infections can cause inflammation and mucus obstruction in the airways. Therefore, the nurse should advise the client to avoid these factors and to seek medical attention if they occur.

Choice C reason: Overdose of albuterol and alcohol consumption are not recommended for anyone, but they are not the main factors that can aggravate COPD. Albuterol is a bronchodilator that can help relax the muscles around the airways and improve breathing, but it can also cause side effects, such as palpitations, tremors, and anxiety, if taken in excess. Alcohol consumption can impair the immune system and the liver function, but it does not directly affect the lungs or the airways.

Choice D reason: Excessive bedrest and lack of exercise are not beneficial for anyone, but they are not the main factors that can exacerbate COPD. Bedrest can lead to muscle weakness and deconditioning, while lack of exercise can reduce the cardiovascular and respiratory fitness. However, these factors do not cause inflammation or obstruction in the airways, which are the main features of COPD. The nurse should encourage the client to maintain a moderate level of physical activity and to follow a pulmonary rehabilitation program if available.

Choice A reason: Obtaining a prostate-specific antigen blood level test is not a way to reduce risk factors for BPH, but a way to screen for prostate cancer, which is a different condition. Prostate-specific antigen (PSA) is a protein produced by the prostate gland, and its level may be elevated in men with prostate cancer or other prostate problems, such as BPH or prostatitis. However, PSA testing is not recommended for all men, and it has some limitations and risks. The nurse should discuss the benefits and harms of PSA testing with the client and help him make an informed decision.

Choice B reason: Taking vitamin supplements is not a proven way to reduce risk factors for BPH, and it may have some adverse effects, such as interactions with medications or increased bleeding. There is no clear evidence that any specific vitamin or mineral can prevent or treat BPH, and some studies have suggested that high doses of certain vitamins, such as vitamin E or folic acid, may increase the risk of prostate cancer. The nurse should advise the client to eat a balanced diet that includes fruits, vegetables, whole grains, and lean proteins, and to consult a doctor before taking any supplements.

Choice C reason: Increasing physical activity is a beneficial way to reduce risk factors for BPH, as well as to improve overall health and well-being. Physical activity can help maintain a healthy weight, lower blood pressure, reduce inflammation, and enhance blood flow to the pelvic area, which may prevent or delay the development of BPH. The nurse should encourage the client to engage in moderate-intensity aerobic exercise, such as brisk walking, cycling, or swimming, for at least 150 minutes per week, and to include some strength training and flexibility exercises as well.

Choice D reason: Consuming a high protein diet is not a helpful way to reduce risk factors for BPH, and it may have some negative effects, such as increasing the risk of kidney stones, gout, or osteoporosis. A high protein diet may also increase the intake of saturated fat, cholesterol, and sodium, which can raise the risk of cardiovascular disease and hypertension, which are also risk factors for BPH. The nurse should advise the client to limit the intake of animal protein, such as red meat, poultry, eggs, and dairy products, and to choose plant-based protein sources, such as beans, nuts, seeds, and soy products, more often.

Choice A reason: Isolating the client from other clients, family, and healthcare workers not wearing proper PPE is the most important action that the nurse should take, because it can prevent the transmission of COVID-19, which is a highly contagious respiratory disease caused by a novel coronavirus. The client has symptoms that are consistent with COVID-19, such as conjunctivitis, loss of taste and smell, and recent travel history, and the nasal swab test can confirm the diagnosis. The nurse should follow the infection control precautions, such as wearing a mask, gloves, gown, and eye protection, and place the client in a private room with negative pressure ventilation, if available.

Choice B reason: Reporting the COVID-19 result to the local health department according to CDC guidelines is an important action that the nurse should take, but it is not the most important one. Reporting the COVID-19 result can help the public health authorities to monitor the epidemiology, track the contacts, and implement the interventions to control the outbreak. However, reporting the result can only be done after the test is completed and confirmed, which may take some time. The nurse should prioritize the immediate isolation of the client to prevent the spread of the virus.

Choice C reason: Teaching the client to wear a mask, hand wash, and social distance to prevent spreading the virus is an important action that the nurse should take, but it is not the most important one. Teaching the client to wear a mask, hand wash, and social distance can help the client to protect themselves and others from COVID-19, which can be transmitted through respiratory droplets, contact, and aerosols. However, teaching the client these measures can only be effective if the client follows them and adheres to the isolation guidelines. The nurse should first isolate the client and then provide the education.

Choice D reason: Explaining to the client to inform others that they may have been potentially exposed in the last 14 days is an important action that the nurse should take, but it is not the most important one. Explaining to the client to inform others that they may have been potentially exposed in the last 14 days can help the client to notify their close contacts, such as family, friends, co-workers, and travel companions, who may have been at risk of COVID-19 infection. However, explaining to the client this information can only be useful if the client cooperates and remembers their contacts. The nurse should first isolate the client and then assist the client with the contact tracing.

Choice A reason: Administering analgesics on a fixed and continuous schedule is the most important intervention that the nurse should include in this client’s plan of care, because it can provide consistent and adequate pain relief for the client with metastatic cancer, who is likely to have chronic and severe pain. The nurse should follow the principles of cancer pain management, such as using the WHO analgesic ladder, titrating the dose according to the pain intensity, and using a multimodal approach that combines opioids, non-opioids, and adjuvants.

Choice B reason: Frequently evaluating the client’s pain is an important intervention that the nurse should include in this client’s plan of care, but it is not the most important one. Evaluating the client’s pain can help the nurse to assess the effectiveness of the analgesics, identify the characteristics and causes of the pain, and adjust the pain management plan accordingly. However, evaluating the pain alone is not enough to provide pain relief, and the nurse should also implement the appropriate interventions based on the evaluation.

Choice C reason: Replacing transdermal analgesic patches every 72 hours is not a relevant intervention that the nurse should include in this client’s plan of care, because it is not applicable to the client’s situation. Transdermal analgesic patches are a form of opioid delivery that can provide long-lasting pain relief, but they are not suitable for acute or breakthrough pain, and they have a delayed onset of action. The client in this scenario is receiving IV analgesics, which have a faster onset and shorter duration of action, and are more appropriate for acute or breakthrough pain.

Choice D reason: Monitoring the client for break-through pain is an important intervention that the nurse should include in this client’s plan of care, but it is not the most important one. Break-through pain is a sudden and transient increase in pain that occurs despite the use of regular analgesics, and it can be caused by various factors, such as movement, infection, or tumor progression. The nurse should monitor the client for break-through pain and administer rescue doses of analgesics as needed. However, monitoring the client for break-through pain is not enough to prevent or treat the pain, and the nurse should also administer analgesics on a fixed and continuous schedule to maintain a steady level of pain relief.

Choice A reason: Calculating gestation from last menstrual cycle is not a reliable way to determine if the client is pregnant, and it is not an urgent intervention that the nurse should implement immediately. The last menstrual cycle may not reflect the actual date of conception, and it may vary depending on the client's cycle length, ovulation time, and other factors. The nurse should use a more accurate and objective method to confirm or rule out pregnancy, such as a urine or blood test.

Choice B reason: Continuing with surgery as scheduled is not a safe or ethical intervention that the nurse should implement immediately, without verifying the client's pregnancy status. Surgery, especially abdominal surgery, can pose significant risks to the client and the fetus, such as bleeding, infection, anesthesia complications, preterm labor, and miscarriage. The nurse should inform the surgical team about the possibility of pregnancy and obtain the client's informed consent before proceeding with surgery.

Choice C reason: Performing a bedside pregnancy test is the most appropriate and timely intervention that the nurse should implement immediately, given the client's situation. A bedside pregnancy test is a simple and quick way to detect the presence of human chorionic gonadotropin (hCG), a hormone produced by the placenta, in the client's urine. A positive result indicates that the client is pregnant, and a negative result indicates that the client is not pregnant. The nurse should perform the test as soon as possible and report the result to the surgical team and the client.

Choice D reason: Notifying the surgical team to cancel the surgery is not a necessary or prudent intervention that the nurse should implement immediately, without confirming the client's pregnancy status. Canceling the surgery may delay the treatment of the client's acute appendicitis, which can lead to serious complications, such as perforation, abscess, peritonitis, and sepsis. The nurse should first perform a bedside pregnancy test and then discuss the risks and benefits of surgery with the surgical team and the client.

Choice A reason: Teaching the client relaxation techniques is a helpful action that the nurse can implement, but it is not the most important one. Relaxation techniques, such as deep breathing, meditation, or guided imagery, can help the client cope with stress, anxiety, and agitation, which are common symptoms of Grave’s disease, a condition that causes hyperthyroidism and overactivity of the thyroid gland. However, relaxation techniques alone cannot address the client’s physical needs, such as hydration, nutrition, and electrolyte balance, which are more urgent and critical.

Choice B reason: Determining the client’s food preferences is a considerate action that the nurse can implement, but it is not the most important one. Food preferences, such as taste, texture, temperature, and variety, can affect the client’s appetite and willingness to eat, which are important factors for maintaining adequate nutrition and weight. However, food preferences may not be the main reason for the client’s refusal to eat, and they may not be enough to overcome the client’s metabolic demands, which are increased by Grave’s disease.

Choice C reason: Maintaining a patent intravenous site is the most important action that the nurse should implement, given the client’s situation. A patent intravenous site can allow the nurse to administer fluids, electrolytes, medications, and nutrients to the client, who is at risk of dehydration, malnutrition, and complications from Grave’s disease, such as thyroid storm, cardiac arrhythmias, and infection. The nurse should monitor the client’s vital signs, fluid intake and output, blood glucose, and thyroid function tests, and adjust the intravenous therapy accordingly.

Choice D reason: Keeping room temperature cool is a supportive action that the nurse can implement, but it is not the most important one. Room temperature can affect the client’s comfort and thermoregulation, which are impaired by Grave’s disease, which causes heat intolerance, sweating, and fever. However, room temperature alone cannot correct the underlying hormonal imbalance or the systemic effects of Grave’s disease, and it may not be sufficient to prevent the client from becoming restless and agitated.

Choice A reason: Corticosteroid cream was applied to eczema is not a useful information in determining the possible cause of the symptoms, because it is a treatment that can reduce the inflammation and itching of eczema, not a trigger that can worsen it. Corticosteroid cream should be used as prescribed by the doctor, and the nurse should instruct the client on how to apply it correctly and safely.

Choice B reason: A grandson and his new dog recently visited is a useful information in determining the possible cause of the symptoms, because it can indicate that the client was exposed to an allergen or an irritant that can trigger an eczema flare-up. Some people with eczema may have allergic reactions to animal dander, saliva, or fur, which can cause skin inflammation, redness, and itching. The nurse should ask the client about their history of allergies and their contact with the dog, and advise them to avoid or minimize exposure to potential allergens.

Choice C reason: An old friend with eczema came for a visit is not a useful information in determining the possible cause of the symptoms, because eczema is not a contagious condition that can be transmitted from person to person. Eczema is a chronic skin disorder that causes dry, itchy, and inflamed skin, and it is influenced by genetic, environmental, and immune factors. The nurse should reassure the client that eczema is not infectious and that they can maintain social relationships with other people with eczema.

Choice D reason: Recently received an influenza immunization is not a useful information in determining the possible cause of the symptoms, because there is no evidence that influenza immunization can cause or worsen eczema. Influenza immunization is a preventive measure that can protect the client from getting the flu, which can be a serious and sometimes fatal illness, especially for people with chronic conditions, such as eczema. The nurse should encourage the client to get vaccinated for influenza and other diseases, as recommended by the doctor.

Choice A reason: Reorienting to day and time frequently is a nursing intervention that the nurse should implement, because it can help the client to reduce confusion, anxiety, and disorientation, which may contribute to the auditory hallucinations. The nurse should use simple and clear language, speak slowly and calmly, and provide cues and reminders, such as a clock, a calendar, or a picture, to help the client to orient to reality.

Choice B reason: Applying soft wrist restraints bilaterally is not a nursing intervention that the nurse should implement, unless it is absolutely necessary and ordered by the doctor. Restraints can increase the client's agitation, anxiety, and fear, and they can also cause physical and psychological harm, such as skin breakdown, nerve damage, or loss of dignity. The nurse should use restraints only as a last resort, after trying other less restrictive alternatives, such as verbal de-escalation, distraction, or medication.

Choice C reason: Administering a PRN dose of lorazepam is a nursing intervention that the nurse should implement, if it is prescribed by the doctor and indicated by the client's condition. Lorazepam is a benzodiazepine that can help the client to relax, reduce anxiety, and sedate the central nervous system, which may alleviate the auditory hallucinations. The nurse should monitor the client's vital signs, level of consciousness, and respiratory status, and report any adverse effects, such as hypotension, bradycardia, or respiratory depression.

Choice D reason: Turning the television on for distraction is not a nursing intervention that the nurse should implement, because it can worsen the client's auditory hallucinations, confusion, and agitation. The television can provide too much stimulation, noise, and information, which can overload the client's sensory perception and interfere with their ability to distinguish reality from hallucination. The nurse should provide a quiet and calm environment, and limit the sources of auditory input.

Choice E reason: Presenting a calm, supportive demeanor is a nursing intervention that the nurse should implement, because it can help the client to feel safe, comfortable, and respected, and to establish a trusting relationship with the nurse. The nurse should show empathy, compassion, and patience, and avoid arguing, criticizing, or dismissing the client's hallucinations. The nurse should acknowledge the client's feelings, validate their distress, and reassure them that they are not alone.

Choice A reason: Reorienting to day and time frequently is a nursing intervention that the nurse should implement, because it can help the client to reduce confusion, anxiety, and disorientation, which may contribute to the auditory hallucinations. The nurse should use simple and clear language, speak slowly and calmly, and provide cues and reminders, such as a clock, a calendar, or a picture, to help the client to orient to reality.

Choice B reason: Applying soft wrist restraints bilaterally is not a nursing intervention that the nurse should implement, unless it is absolutely necessary and ordered by the doctor. Restraints can increase the client's agitation, anxiety, and fear, and they can also cause physical and psychological harm, such as skin breakdown, nerve damage, or loss of dignity. The nurse should use restraints only as a last resort, after trying other less restrictive alternatives, such as verbal de-escalation, distraction, or medication.

Choice C reason: Administering a PRN dose of lorazepam is a nursing intervention that the nurse should implement, if it is prescribed by the doctor and indicated by the client's condition. Lorazepam is a benzodiazepine that can help the client to relax, reduce anxiety, and sedate the central nervous system, which may alleviate the auditory hallucinations. The nurse should monitor the client's vital signs, level of consciousness, and respiratory status, and report any adverse effects, such as hypotension, bradycardia, or respiratory depression.

Choice D reason: Turning the television on for distraction is not a nursing intervention that the nurse should implement, because it can worsen the client's auditory hallucinations, confusion, and agitation. The television can provide too much stimulation, noise, and information, which can overload the client's sensory perception and interfere with their ability to distinguish reality from hallucination. The nurse should provide a quiet and calm environment, and limit the sources of auditory input.

Choice E reason: Presenting a calm, supportive demeanor is a nursing intervention that the nurse should implement, because it can help the client to feel safe, comfortable, and respected, and to establish a trusting relationship with the nurse. The nurse should show empathy, compassion, and patience, and avoid arguing, criticizing, or dismissing the client's hallucinations. The nurse should acknowledge the client's feelings, validate their distress, and reassure them that they are not alone.