Choice A reason:

Assessing the client's vital signs, oxygen saturation, and respiratory status is the first action the nurse should take because it provides baseline data on the client's condition and helps to identify any urgent needs or complications. This is consistent with the principle of prioritizing assessment before intervention and following the ABCs (airway, breathing, circulation) of emergency care.

Choice B reason:

Educating the client about the disease process and preventive measures is an important action, but not the first one. The nurse should assess the client's learning needs, readiness, and preferences before providing education. Education is also a lower priority than addressing any immediate threats to the client's health or safety.

Choice C reason:

Collaborating with the physician to prescribe antibiotics and bronchodilators is an appropriate action for a client with pneumonia, but not the first one. The nurse should assess the client's condition and obtain relevant laboratory and diagnostic tests before initiating pharmacological interventions. The nurse should also follow the physician's orders and the facility's policies and protocols when administering medications.

Choice D reason:

Setting goals and outcomes for the client's recovery and discharge is a necessary step in the nursing process, but not the first one. The nurse should assess the client's current status, needs, preferences, and resources before planning care. The nurse should also involve the client and family in setting realistic and measurable goals and outcomes.

Choice A reason:

The client will have no signs of infection in the wound by day 7. This is an appropriate outcome because it indicates that the wound is healing properly and that the client is receiving adequate wound care and infection prevention measures. Infection can delay wound healing and increase the risk of complications.

Choice B reason:

The client will report pain level of 4/10 or less during dressing changes. This is not an appropriate outcome because it does not address the wound healing process or the prevention of further skin breakdown. Pain management is important for the client's comfort and quality of life, but it is not a specific goal for pressure ulcer care.

Choice C reason:

The client will consume at least 75% of meals and snacks daily. This is an appropriate outcome because it indicates that the client is receiving adequate nutrition to support wound healing. Nutrition plays a vital role in tissue integrity and repair, and the client should consume enough calories, protein, and micronutrients to meet their needs.

Choice D reason:

The client will reposition self in bed every 2 hours with assistance. This is not an appropriate outcome because it does not reflect the current evidence-based practice for pressure ulcer prevention and treatment. Repositioning should be done more frequently than every 2 hours, and the frequency should be individualized based on the client's risk factors, skin condition, comfort, and support surfaces.

Choice E reason:

The client will demonstrate proper wound care technique before discharge. This is an appropriate outcome because it indicates that the client has learned how to care for their wound at home and prevent further skin breakdown. Wound care education is essential for the client's self-management and adherence to the treatment plan.

Choice A reason:

Checking the pain level and location before and after giving the medication is an example of an independent intervention because it is within the nurse's scope of practice and does not require a provider's order. It is also part of the nursing process to assess the patient's pain and evaluate the effectiveness of the intervention.

Choice B reason:

Flushing the IV line with normal saline before and after giving the medication is not an independent intervention because it is a dependent intervention that requires a provider's order. It is also a standard procedure for administering IV medications to prevent occlusion and contamination of the IV line.

Choice C reason:

Monitoring the vital signs and level of consciousness every 15 minutes after giving the medication is not an independent intervention because it is a dependent intervention that requires a provider's order. It is also a safety measure to detect any adverse effects of the medication, such as respiratory depression, hypotension, or sedation.

Choice D reason:

Asking the physician to order naloxone in case of an adverse reaction to the medication is not an independent intervention because it is a collaborative intervention that involves consultation with another health care professional. It is also a precautionary measure to have an opioid antagonist available in case of overdose or severe respiratory depression.

Choice A reason:

Teaching the client some exercises to strengthen the core muscles and improve posture is an example of an independent intervention, not a collaborative one. An independent intervention is one that the physical therapist can perform without consulting or coordinating with other members of the health care team.

Choice B reason:

Applying heat therapy to the client's back for 15 minutes before starting the exercises is also an example of an independent intervention, not a collaborative one. Heat therapy is a modality that the physical therapist can use to reduce pain and stiffness, and prepare the client for exercise.

Choice C reason:

Documenting the client's progress and response to the exercises in the medical record is an example of a professional responsibility, not a collaborative intervention. Documentation is essential for communication, quality improvement, and legal purposes, but it does not involve working with other health care providers.

Choice D reason:

Coordinating with the nurse to schedule the exercises after the client receives analgesics is an example of a collaborative intervention. A collaborative intervention is one that requires consultation or coordination with other members of the health care team to achieve a common goal. In this case, the physical therapist and the nurse work together to ensure that the client has adequate pain relief before engaging in exercise, which can improve the client's comfort and compliance.

Choice A reason:

Reviewing the client's medications and dosage instructions with them is an important part of discharge planning for a client who has diabetes mellitus. This helps to ensure that the client understands how to take their medications correctly, avoid errors, and prevent adverse effects. It also provides an opportunity for the nurse to answer any questions or concerns the client may have about their medications.

Choice B reason:

Evaluating the client's blood glucose levels and insulin administration technique is another essential part of discharge planning for a client who has diabetes mellitus. This helps to assess the client's ability to monitor and manage their blood glucose levels at home, and to identify any areas that need improvement or reinforcement. It also helps to prevent complications such as hypoglycemia or hyperglycemia, which can be life-threatening.

Choice C reason:

Referring the client to a home health nurse or a diabetes educator as needed is a beneficial part of discharge planning for a client who has diabetes mellitus. This helps to provide ongoing support, education, and guidance for the client after they leave the hospital. It also helps to promote self-care, adherence, and quality of life for the client who has a chronic condition that requires lifelong management.

Choice D reason:

All of the above actions are appropriate and necessary for the nurse to take as part of discharge planning for a client who has diabetes mellitus. They all aim to prepare the client for a safe and successful transition from the hospital to the home setting, and to prevent or reduce the risk of complications or readmission.