Choice A rationale

Determining the elasticity of the client’s skin turgor is not directly related to nasopharyngeal suctioning. Skin turgor assessment is typically used to evaluate hydration status and does not provide information about the respiratory status or the need for suctioning.

Choice B rationale

Auscultating the bowel sounds in all four quadrants is unrelated to nasopharyngeal suctioning. Bowel sounds assessment is important for gastrointestinal evaluation but does not help in assessing the respiratory status or the effectiveness of suctioning.

Choice C rationale

Palpating the client’s pedal pulse volume bilaterally is not relevant to nasopharyngeal suctioning. This assessment is used to evaluate peripheral circulation and does not provide information about the respiratory status or the need for suctioning.

Choice D rationale

Observing the client’s skin and mucous membranes is crucial during nasopharyngeal suctioning. This assessment helps determine the client’s oxygenation status and the presence of cyanosis, which can indicate hypoxia. It also helps in identifying any trauma or irritation caused by the suctioning procedure.

Choice A rationale

Requesting removal initiated by the Health Information Manager is not necessary in this scenario. The focus should be on accurately documenting the missed occurrence rather than removing previously entered documentation. This approach does not address the need to document the 0900 occurrence.

Choice B rationale

Creating an electronic correction after 1400 notes are officially unlocked implies that there was an error in the original documentation. Since the issue here is not correcting an error but rather adding missed documentation, creating a correction may not be appropriate.

Choice C rationale

Entering the occurrence after the 1400 notes and identifying it as a “late entry” is an option, but it may not provide sufficient clarity regarding the timing of the documentation. Using a “late entry” label could potentially lead to confusion or misinterpretation.

Choice D rationale

Making an electronic addendum following the 1400 documentation is the best approach. An electronic addendum allows the nurse to add additional information to the chart without altering the original entry. This approach maintains the integrity of the original documentation while clearly indicating that the 0900 occurrence was added after the fact. It ensures accuracy and transparency in the medical record.

Choice A rationale

Administering PRN oral pain medication without further assessment may not be appropriate, as the client’s pain needs must be fully evaluated before intervening with medication. Pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.

Choice B rationale

Reviewing the pain medications prescribed is important, particularly if the client is exhibiting signs of uncontrolled pain. However, this intervention should be secondary to further assessment of the client’s current pain status.

Choice C rationale

Administering PRN oral pain medication without further assessment may not be appropriate, as the client’s pain needs must be fully evaluated before intervening with medication. Pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.

Choice D rationale

Asking the client what is causing the grimacing is the correct intervention to implement first. Nonverbal cues, such as grimacing, can indicate the presence of pain, even if the client denies it verbally. By closely monitoring the client’s nonverbal behavior, the nurse can gather additional information about the client’s pain experience and make appropriate interventions based on a comprehensive assessment.

Choice A rationale

Positioning the head with the chin tilted slightly downward is an appropriate action when feeding a client with a CVA. This position helps prevent aspiration by closing the airway and directing food away from the trachea.

Choice B rationale

Allowing 30 minutes of rest before feeding is an appropriate action. Resting before feeding can help improve digestion and reduce the risk of aspiration by ensuring the client is alert and responsive during feeding.

Choice C rationale

Placing food on the unaffected side of the mouth is an appropriate action when feeding a client with a CVA. This technique helps the client manage food more effectively and reduces the risk of aspiration.

Choice D rationale

Raising the head of the bed to 60 degrees is not sufficient to prevent aspiration. The head of the bed should be elevated 45 to 90 degrees to ensure proper positioning and reduce the risk of aspiration. Therefore, if the UAP raises the head of the bed to only 60 degrees, it indicates the need for additional teaching.

Choice A rationale

Wearing gloves to dispose of the needle and syringe is a good practice to prevent needlestick injuries and contamination. However, it does not directly indicate an understanding of standard precautions, which emphasize hand hygiene as a primary measure.

Choice B rationale

Removing the needle before discarding used syringes is not recommended as it increases the risk of needlestick injuries. Standard precautions emphasize the safe disposal of sharps in puncture-resistant containers without manipulating the needle.

Choice C rationale

Donning a face mask before administering medication is not a standard precaution for handling syringes and needles. Standard precautions focus more on hand hygiene and the use of gloves when there is a risk of exposure to blood or body fluids.

Choice D rationale

Washing hands before handling the needle and syringe is a fundamental aspect of standard precautions. Hand hygiene is the most effective way to prevent the transmission of infections and is a clear indication of understanding standard precautions.

Choice A rationale

Monitoring the client’s white blood cell count is essential to assess the presence and severity of infection. An elevated white blood cell count can indicate an ongoing infection, including MRSA.

Choice B rationale

Sending wound drainage for culture and sensitivity is crucial to identify the specific bacteria causing the infection and to determine the most effective antibiotics for treatment.

Choice C rationale

Instituting contact precautions for staff and visitors is necessary to prevent the spread of MRSA. This includes wearing gloves and gowns when entering the client’s room and ensuring proper hand hygiene.

Choice D rationale

Explaining the purpose of a low bacteria diet is not relevant to the management of MRSA infections. MRSA management focuses on infection control measures and appropriate antibiotic therapy.

Choice E rationale

Using standard precautions and wearing a mask is not specific to MRSA management. While standard precautions are always important, contact precautions are more relevant for preventing the spread of MRSA.

Choice A rationale

Telling the client to dress the right arm first is practical advice but does not address the client’s frustration and emotional state. It is important to acknowledge the client’s feelings to provide empathetic care.

Choice B rationale

Offering a class on dressing tomorrow does not address the immediate frustration and emotional response of the client. The client needs support and understanding in the moment.

Choice C rationale

Acknowledging that dressing must be a frustrating experience for the client shows empathy and understanding. It validates the client’s feelings and helps build a therapeutic relationship.

Choice D rationale

Mentioning a policy against staff harassment is inappropriate and does not address the client’s frustration. It may escalate the situation and damage the nurse-client relationship.

Choice A rationale

Releasing the manometer valve immediately is not appropriate as it does not allow for an accurate measurement of systolic blood pressure.

Choice B rationale

Documenting the absence of the radial pulse is not the correct action. The nurse needs to continue the procedure to obtain an accurate systolic blood pressure reading.

Choice C rationale

Inflating the blood pressure cuff to 120 mm Hg is the correct action. The nurse should inflate the cuff 30 mm Hg above the point where the radial pulse is no longer palpable to ensure an accurate measurement.

Choice D rationale

Recording a palpable systolic pressure of 90 mm Hg is incorrect. The nurse needs to inflate the cuff further to obtain an accurate systolic blood pressure reading.

Choice A rationale

Eschar and slough are indicative of necrotic tissue and are not signs of proper healing. Eschar is a dry, dark scab or falling away of dead skin, typically caused by a burn, or by the bite of a mite or other insect. Slough is a layer or mass of dead tissue separated from surrounding living tissue, as in a wound, sore, or inflammation. Both eschar and slough need to be removed for proper wound healing to occur.

Choice B rationale

Erythema and serosanguineous exudate can be present in the early stages of wound healing, but one week post-surgery, these signs may indicate inflammation or infection rather than proper healing. Erythema is redness of the skin caused by increased blood flow to the capillaries, often a sign of infection or irritation. Serosanguineous exudate is a thin, watery fluid that is slightly pink due to the presence of small amounts of blood, which can be normal immediately after surgery but should decrease over time.

Choice C rationale

A well-approximated incision site is a sign of proper healing. This means that the edges of the wound are close together and aligned, which promotes faster and more efficient healing. Proper approximation of the wound edges reduces the risk of infection and promotes the formation of a strong, healthy scar.

Choice D rationale

Beefy red granulation tissue is a sign of healing in open wounds, not in surgical incisions that are closed. Granulation tissue is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process. It is typically bright red or pink and indicates that the wound is healing from the inside out. However, in a surgical incision that is healing properly, the wound edges should be well approximated, and granulation tissue should not be visible.

Choice A rationale

Giving the client a hug and saying, “It is okay to cry when you are sad,” may be comforting, but it may also be seen as intrusive and not respecting the client’s personal space. Physical touch should be used cautiously and only when the nurse is certain that it is welcome and appropriate. Additionally, this response does not encourage the client to express their feelings or provide an opportunity for the nurse to understand the underlying cause of the client’s distress.

Choice B rationale

Saying, “I am sorry to disturb you at a difficult time. This can wait until later,” acknowledges the client’s distress but does not offer immediate support or an opportunity for the client to express their feelings. It may also give the impression that the nurse is not available to provide emotional support when needed.

Choice C rationale

While touching the client’s forearm, asking, “Would you like to talk about it?” is the best response as it shows empathy and offers the client an opportunity to express their feelings. This response respects the client’s personal space while also providing a gentle touch that can be comforting. It opens the door for communication and allows the nurse to provide emotional support and address any concerns the client may have.

Choice D rationale

Saying, “This is a bad time. I can see you are upset. I can come back later,” acknowledges the client’s distress but does not offer immediate support or an opportunity for the client to express their feelings. It may also give the impression that the nurse is not available to provide emotional support when needed.

Choice A rationale

Inspecting crutches to ensure rubber tips are intact is important for safety, but it does not indicate an understanding of the proper crutch walking technique. Proper crutch walking involves using the crutches correctly to avoid injury and ensure mobility.

Choice B rationale

Practicing bicep and triceps isometric exercises can help strengthen the muscles needed for crutch walking, but it does not demonstrate an understanding of the actual crutch walking technique. The focus should be on how the crutches are used during walking.

Choice C rationale

Progressing to foot touchdown and weight-bearing of the affected leg is a part of the rehabilitation process, but it does not specifically indicate proper crutch walking technique. Proper crutch walking involves the correct use of crutches to support the body weight.

Choice D rationale

Bearing body weight on the palms of hands during the crutch gait is the correct technique for three-point gait crutch walking. This method ensures that the weight is distributed properly and reduces the risk of injury to the underarms and shoulders.

Choice A rationale

Assessing the strength of deep tendon reflexes is important in evaluating neuromuscular function, but it is not the most critical intervention for a client with hyperkalemia. Hyperkalemia primarily affects cardiac function, so monitoring the heart is crucial.

Choice B rationale

Determining the apical pulse rate and rhythm is the most important intervention for a client with a serum potassium level of 7.5 mEq/L. Hyperkalemia can cause life-threatening cardiac arrhythmias, and monitoring the heart rate and rhythm can help detect early signs of these complications.

Choice C rationale

Observing the color and amount of urine can provide information about kidney function and hydration status, but it is not the most critical intervention for hyperkalemia. The primary concern with hyperkalemia is its effect on the heart.

Choice D rationale

Comparing muscle strength bilaterally can help assess neuromuscular function, but it is not the most critical intervention for hyperkalemia. The focus should be on monitoring cardiac function to prevent life-threatening complications.

Choice A rationale

A urine specific gravity of 1.015 is within the normal range and does not indicate dehydration. Dehydration typically results in a higher urine specific gravity due to the concentration of solutes in the urine.

Choice B rationale

A urine specific gravity of 1.005 is lower than normal and indicates dilute urine, which is not consistent with dehydration. Dehydration would result in more concentrated urine with a higher specific gravity.

Choice C rationale

A urine specific gravity of 1.035 indicates highly concentrated urine, which is consistent with dehydration. When a client has a history of vomiting and diarrhea, they are likely to be dehydrated, leading to a higher urine specific gravity.

Choice D rationale

A urine specific gravity of 1.025 is slightly higher than normal but not as high as 1.035. While it may indicate some level of concentration, it is not as indicative of severe dehydration as a specific gravity of 1.035.

Choice A rationale

Lubricating the thermometer before inserting it into the ear is not a standard practice for using a tympanic thermometer. Tympanic thermometers are designed to be used without lubrication, and using lubrication could interfere with the accuracy of the reading.

Choice B rationale

Holding the thermometer in place for a full three minutes is unnecessary for tympanic thermometers. These thermometers provide quick readings, usually within a few seconds, and holding it for longer does not improve accuracy.

Choice C rationale

Pulling the client’s auricle down and back is the correct technique for infants and young children. For adults, the correct technique is to pull the auricle up and back to straighten the ear canal for an accurate reading.

Choice D rationale

Using positive reinforcement to affirm that the procedure is being performed correctly is the appropriate action. The UAP is using the correct technique by pulling the client’s auricle up and back, which is the proper method for adults.

Choice A rationale

The SBAR (Situation, Background, Assessment, Recommendation) format is specifically designed for critical communication, particularly when reporting a change in a client’s condition to the healthcare provider. This structured communication tool ensures that essential information is conveyed clearly and concisely, reducing the risk of miscommunication and enhancing patient safety.

Choice B rationale

Completing discharge teaching to a client and family members typically involves providing comprehensive instructions and education, which may not fit the concise and focused nature of the SBAR format. Discharge teaching requires a more detailed and interactive approach to ensure understanding and compliance.

Choice C rationale

Obtaining clarification from a client’s healthcare power-of-attorney involves a more conversational and detailed exchange of information, which may not align with the structured and concise nature of the SBAR format. This interaction often requires a thorough discussion to ensure all aspects are understood.

Choice D rationale

Offering therapeutic support and comfort to a grieving family is a sensitive and empathetic interaction that requires a compassionate and patient-centered approach. The SBAR format is not suitable for this type of communication, as it is designed for conveying critical information quickly and efficiently.

Choice A rationale

Inserting a rectal tube at specified intervals is not a standard practice for bowel training regimens. This intervention is typically reserved for specific medical conditions and is not recommended for routine management of chronic fecal incontinence.

Choice B rationale

Assisting the client to a bedside commode 30 minutes after meals leverages the natural gastrocolic reflex, which stimulates bowel movements after eating. This intervention helps establish a regular bowel routine and is a key component of bowel retraining programs.

Choice C rationale

Encouraging the use of incontinence briefs does not address the underlying issue of bowel incontinence and may not help in establishing a regular bowel routine. This intervention is more focused on managing the symptoms rather than treating the condition.

Choice D rationale

Administering a glycerin suppository 15 minutes after meals can stimulate bowel movements, but it is not the first-line intervention for establishing a bowel training regimen. This approach may be used as an adjunct to other bowel retraining techniques.

Choice A rationale

Testing for a gag reflex before performing oral care is a standard practice to ensure the client’s safety and prevent aspiration. This action does not indicate a need for additional training.

Choice B rationale

Placing the client in a supine position is incorrect and indicates a need for additional training. The correct position for performing oral care on an unconscious client is a side-lying position to prevent aspiration and ensure secretions can drain from the mouth.

Choice C rationale

Suctioning secretions from the posterior pharynx is a necessary action to maintain airway patency and prevent aspiration. This action does not indicate a need for additional training.

Choice D rationale

Using an oral airway to keep the teeth apart is a standard practice to facilitate oral care and prevent the client from biting down on the caregiver’s fingers or equipment. This action does not indicate a need for additional training.

Choice A rationale

Verifying the placement of the pulse oximeter is the first step to ensure the accuracy of the oxygen saturation reading. An incorrect placement can lead to inaccurate readings, and addressing this issue can help determine if further interventions are needed.

Choice B rationale

Increasing the oxygen to 3 L/minute may be necessary if the oxygen saturation remains low after verifying the pulse oximeter placement. However, this should be done after ensuring the accuracy of the initial reading.

Choice C rationale

Switching to a non-rebreather mask is not the immediate action to take. Non-rebreather masks deliver a high concentration of oxygen, typically reserved for severe hypoxia. The patient’s oxygen saturation is low, but not critically low.

Choice D rationale

Removing the nasal cannula is not appropriate as it would further decrease the oxygen supply to the patient. The goal is to improve oxygenation, not reduce it.

Choice A rationale

Initiating a fall risk protocol is not necessary when the client demonstrates an upright posture and a smooth, steady gait. Fall risk protocols are typically initiated when there are signs of instability or a history of falls.

Choice B rationale

Recording the client’s ability to perform ADLs safely is the appropriate action. This documentation provides a baseline for the client’s functional status and helps in planning further care. It also ensures that the client’s current abilities are noted for future reference.

Choice C rationale

Determining the client’s activity tolerance is important but not the immediate next step after observing a smooth and steady gait. This assessment can be done later to evaluate the client’s endurance and capacity for physical activities.

Choice D rationale

Teaching the client to shorten the stride to prevent falls is unnecessary when the client’s gait is already smooth and steady. This advice is more relevant for clients who show signs of instability or a tendency to fall.

Choice A rationale

Contraction of the left pupil when light shines in the right eye is a normal consensual pupillary response and does not need to be documented in charting by exception. This finding is within normal limits and does not indicate any deviation from the expected outcome.

Choice B rationale

Basilar lung sounds that are diminished in the left lung should be documented because this finding deviates from the normal lung sounds and indicates a potential issue that needs further investigation. Charting by exception focuses on documenting abnormalities or deviations from the norm.

Choice C rationale

Active bowel sounds in the lower right quadrant are a normal finding and do not need to be documented in charting by exception. This assessment is within normal limits and does not indicate any deviation from the expected outcome.

Choice D rationale

Capillary refill of 2 seconds in the lower right foot is a normal finding and does not need to be documented in charting by exception. This assessment is within normal limits and does not indicate any deviation from the expected outcome.

Choice A rationale

Advising the UAP to wear a standard face mask to obtain vital signs and then get fitted for a filter mask before providing personal care is not appropriate. The UAP should be properly equipped with the correct protective gear before any contact with the client.

Choice B rationale

Instructing the UAP that a standard face mask is sufficient to provide care for the assigned client is incorrect. Bacterial meningitis requires droplet precautions, and a standard face mask is sufficient for this type of precaution, not a particulate filter mask.

Choice C rationale

Sending the UAP to be fitted for a particulate filter mask immediately so the UAP can provide care to this client is unnecessary because bacterial meningitis requires droplet precautions, which only necessitate a standard surgical mask, not a particulate filter mask like an N953.

Choice D rationale

Before changing assignments, determining which staff members have fitted particulate filter masks is prudent but not necessary for caring for a client with bacterial meningitis under droplet precautions. The focus should be on ensuring the UAP understands that a standard mask is sufficient.

Choice A rationale

Sending an email to facility administrators reporting the action may not be the most immediate or effective way to address the situation. It could delay the necessary intervention and does not ensure that the issue is resolved promptly.

Choice B rationale

Warning the colleague that copying health information is unlawful is important, but it may not adequately address the potential breach of patient privacy and confidentiality. The colleague may already be aware of the laws but still engage in inappropriate behavior.

Choice C rationale

Disposing of the copies and continuing with client care assignments prevents further unauthorized access to patient information but does not address the issue of the colleague’s inappropriate handling of the records. It is essential to report the incident to the appropriate authority for further investigation and follow-up.

Choice D rationale

Communicating the colleague’s activities to the unit charge nurse is the most appropriate action because it informs the person in charge of the unit about the observed behavior, allowing for immediate intervention and potential corrective action. The unit charge nurse can address the situation promptly and ensure that patient privacy and confidentiality are maintained.

Choice A rationale

Starting to collect the specimen with the next void is the correct action. The 24-hour urine collection for creatinine clearance should start with an empty bladder. The first urine of the day is discarded, and the time is noted.

Choice B rationale

Beginning the collection the next day is unnecessary and would delay the process. It is important to start the collection as soon as possible to avoid further delays.

Choice C rationale

Observing the sample for sediment is not relevant to the collection process. The focus should be on starting the collection with the next void.

Choice D rationale

Emptying the sample into the 24-hour container is incorrect because the first urine sample should be discarded to ensure accurate results.

Choice A rationale

Knowing when the client voided following catheter removal is crucial because it indicates the return of the client’s ability to urinate after catheter removal. It helps assess urinary function and determines if the client is experiencing any urinary retention issues, which could potentially lead to complications such as urinary tract infections or bladder distention.

Choice B rationale

The time of the last dose of IV antibiotic administration is important for managing the client’s urinary tract infection, but it is not as immediately relevant as knowing when the client voided after catheter removal to assess urinary function.

Choice C rationale

Intake and output reports for the previous shift are important for assessing fluid balance and renal function, but knowing when the client voided after catheter removal takes precedence as it directly assesses urinary function and the need for further intervention.

Choice D rationale

The color of the urine during catheter removal may provide some insight into the client’s urinary condition, but it is not as critical as knowing when the client voided after catheter removal to assess urinary function.

Choice A rationale

Asking the client if they understand after each instruction may not be effective if the client is not comfortable expressing confusion or misunderstanding. It does not allow for direct observation of the client’s ability to perform the necessary tasks.

Choice B rationale

Having an interpreter repeat the wound care instructions may be helpful, but it still does not allow for direct observation of the client’s ability to perform the necessary tasks.

Choice C rationale

Having the client demonstrate prescribed wound care is the best way to evaluate the client’s understanding of self-care at home. This allows the nurse to directly observe the client’s ability to perform the necessary tasks and provide feedback and clarification as needed.

Choice D rationale

Providing written instructions in the client’s native language may be helpful, but it does not allow the nurse to directly evaluate the client’s understanding.