Choice A Reason:

Checking the medical record for the client's signature on a previous consent form is incorrect. While a previous consent form might exist in the medical records, for certain procedures or situations, specific, current consent for each instance is often necessary. Verifying a previous consent form may not ensure the client's informed consent for the current procedure.

Choice B Reason:

Having another nurse co-sign the client's consent is incorrect. Co-signing a client's consent by another nurse doesn't substitute for the client's own signature and may not adequately verify the client's informed decision and understanding of the procedure.

Choice C Reason:

Obtaining verbal consent from the client is incorrect. While obtaining verbal consent is important, for invasive procedures like catheter insertion, it's essential to have written, witnessed consent to ensure proper documentation and confirmation that the client is fully informed and agrees to the procedure.

Choice D Reason:

Witnessing the client's signature on a consent form is correct. Express consent for medical procedures typically involves the client signing a consent form after being adequately informed about the procedure, its potential risks, benefits, and alternatives. Witnessing the client's signature on a consent form ensures that the client has provided informed consent for the specific procedure.

Choice A Reason:

Using a filter needle to aspirate the medication is incorrect. Filter needles are typically used for drawing medication from an ampule to filter out any glass particles. However, not all medications from ampules require filter needles. It's important to follow specific guidelines or instructions for the particular medication being administered.

Choice B Reason:

Adding 0.5 ml of diluent to the medication is incorrect. Adding diluent to medication from an ampule is not a standard practice. Ampules usually contain pre-measured doses of medication and are designed for direct withdrawal without dilution. Adding diluent could alter the concentration and effectiveness of the medication.

Choice C Reason:

Cleansing the tip of the ampule with an alcohol swab after opening is correct. This action is essential to ensure that the tip of the ampule is clean before withdrawing the medication. It helps minimize the risk of contamination when accessing the contents of the ampule.

Choice D Reason:

Injecting air into the ampule prior to drawing the medication into a syringe is incorrect. This action is not typically necessary when withdrawing medication from an ampule. Some medications may require air to equalize pressure, but it's crucial to follow specific guidelines for each medication. In most cases, creating positive pressure by injecting air into the ampule is not recommended, as it could affect the stability or integrity of the medication.

Choice A Reason:

Using a filter needle to aspirate the medication is incorrect. Filter needles are typically used for drawing medication from an ampule to filter out any glass particles. However, not all medications from ampules require filter needles. It's important to follow specific guidelines or instructions for the particular medication being administered.

Choice B Reason:

Adding 0.5 ml of diluent to the medication is incorrect. Adding diluent to medication from an ampule is not a standard practice. Ampules usually contain pre-measured doses of medication and are designed for direct withdrawal without dilution. Adding diluent could alter the concentration and effectiveness of the medication.

Choice C Reason:

Cleansing the tip of the ampule with an alcohol swab after opening is correct. This action is essential to ensure that the tip of the ampule is clean before withdrawing the medication. It helps minimize the risk of contamination when accessing the contents of the ampule.

Choice D Reason:

Injecting air into the ampule prior to drawing the medication into a syringe is incorrect. This action is not typically necessary when withdrawing medication from an ampule. Some medications may require air to equalize pressure, but it's crucial to follow specific guidelines for each medication. In most cases, creating positive pressure by injecting air into the ampule is not recommended, as it could affect the stability or integrity of the medication.

Choice A Reason:

Placing the bed in the lowest position before logrolling the client is incorrect. Lowering the bed position isn't directly related to the safety or comfort of the client during logrolling. It's more important to focus on proper body alignment and support for the surgical site.

Choice B Reason:

Placing the client in semi-Fowler's position prior to logrolling is incorrect. Semi-Fowler's position (a reclined position with the head of the bed elevated at a 30-45-degree angle) might be used for comfort, but it's not specifically necessary before logrolling, which is a technique used to move the client while maintaining spinal alignment.

Choice C Reason:

Placing the client's arms above her head prior to logrolling is incorrect. Placing the client's arms above the head isn't typically necessary or recommended before logrolling a postoperative client. It's crucial to prioritize maintaining proper body alignment and minimizing stress on the surgical site during movement.

Choice D Reason:

Placing a pillow between the client's legs prior to logrolling is correct. This action helps maintain proper alignment of the spine and reduces pressure on the surgical site during logrolling. Placing a pillow between the legs provides support and helps prevent excessive twisting or stress on the back.

Choice A Reason:

Placing the bed in the lowest position before logrolling the client is incorrect. Lowering the bed position isn't directly related to the safety or comfort of the client during logrolling. It's more important to focus on proper body alignment and support for the surgical site.

Choice B Reason:

Placing the client in semi-Fowler's position prior to logrolling is incorrect. Semi-Fowler's position (a reclined position with the head of the bed elevated at a 30-45-degree angle) might be used for comfort, but it's not specifically necessary before logrolling, which is a technique used to move the client while maintaining spinal alignment.

Choice C Reason:

Placing the client's arms above her head prior to logrolling is incorrect. Placing the client's arms above the head isn't typically necessary or recommended before logrolling a postoperative client. It's crucial to prioritize maintaining proper body alignment and minimizing stress on the surgical site during movement.

Choice D Reason:

Placing a pillow between the client's legs prior to logrolling is correct. This action helps maintain proper alignment of the spine and reduces pressure on the surgical site during logrolling. Placing a pillow between the legs provides support and helps prevent excessive twisting or stress on the back.

Training the bladder by voiding every 5 hr. is incorrect. For individuals experiencing urinary incontinence, scheduled voiding at regular intervals might be a part of the management plan. However, the specific interval of every 5 hours might not suit everyone, as it depends on individual bladder capacity and function. Scheduled voiding should be tailored to the individual's needs and not solely based on a fixed time frame.

Choice B Reason:

Applying adult diapers at bedtime is incorrect. While using protective garments like adult diapers may manage urinary incontinence during sleep, it doesn't address the underlying issue or provide a solution to improve the condition.

Choice C Reason:

Performing pelvic-muscle exercises is correct. Pelvic floor muscle exercises, also known as Kegel exercises, can help strengthen the muscles that support the bladder and control urine flow. This can potentially improve urinary incontinence by enhancing bladder control.

Choice D Reason:

Drinking citrus juice with meals is incorrect. Citrus juices can irritate the bladder and potentially exacerbate urinary incontinence for some individuals. Advising the consumption of citrus juice might not be beneficial and could worsen symptoms in certain cases.

Choice A Reason:

Discontinuing supplements containing vitamin C 24 hr. before the test is incorrect. While high doses of vitamin C might interfere with the accuracy of some laboratory tests, it typically doesn't impact fecal occult blood testing. However, it's always best to follow specific instructions provided by the healthcare provider or laboratory.

Choice B Reason:

Refraining from consuming pork 7 days before the test. There isn't typically a requirement to avoid specific foods, such as pork, before a fecal occult blood test. The test is designed to detect blood in the stool, regardless of the diet. However, some dietary restrictions might be advised based on specific instructions or conditions, but these are not universally applicable.

Choice C Reason:

Placing a thick layer of stool on the specimen card is incorrect. When collecting a sample for a fecal occult blood test, it's important to follow the specific instructions provided by the healthcare provider or laboratory. Generally, a small portion of stool is applied to the designated area on the specimen card as instructed, rather than applying a thick layer. Applying too much stool can affect the accuracy of the test.

Choice D Reason:

Urinating prior to collecting the stool specimen is correct. This instruction ensures that the urine doesn't contaminate the stool sample, which could potentially affect the accuracy of the test results.

1. Unlock and remove the inner cannula (Step C). This is the initial step because it allows access to the inner cannula for cleaning. Removing it enables further cleaning of the inner cannula and ensures proper hygiene of the tracheostomy.

2. Scrub the inside and outside of the inner cannula with a small brush (Step D). Once the inner cannula is removed, it should be cleaned thoroughly to remove any secretions or debris. Scrubbing with a small brush helps in effectively cleaning both the inside and outside surfaces.

3. Wipe the inside of the inner cannula with a folded pipe cleaner (Step E). Using a pipe cleaner helps to reach areas that a brush might not access easily. It further ensures the removal of any remaining secretions or buildup inside the inner cannula.

4. Cleanse the stoma site with 0.9% sodium chloride solution (Step B). After addressing the inner cannula, the nurse moves to clean the stoma site to prevent infection or irritation. This step ensures the area around the tracheostomy is clean and free from contaminants.

5.Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin (Step A). Lastly, preparing the sterile basin with the saline solution should be done at the start to ensure it's ready for use during the cleaning process. This solution will be utilized for cleaning the stoma site in step B and may also be needed for moistening the brush or pipe cleaner during steps D and E.

Choice A Reason:

Hyperkalemia is incorrect. Vomiting and diarrhea typically lead to a loss of potassium rather than an increase. These conditions often result in depletion of electrolytes, including potassium, due to the loss of fluids.

Choice B Reason:

Hypocalcemia is correct. While prolonged or severe diarrhea could potentially lead to some electrolyte imbalances, hypocalcemia is not typically a primary finding associated with vomiting and diarrhea. Calcium levels may not be significantly affected by these symptoms compared to sodium and potassium.

Choice C Reason:

Hypermagnesemia is incorrect. Similar to calcium, magnesium levels are not usually significantly impacted by vomiting and diarrhea alone. Hypermagnesemia is more commonly associated with excessive intake of magnesium-containing medications or renal dysfunction rather than acute gastrointestinal symptoms.

In a client experiencing vomiting and diarrhea, the loss of fluids and electrolytes due to these symptoms commonly leads to:

Choice D Reason:

Hyponatremia is correct. Vomiting and diarrhea can cause a loss of sodium and water, leading to decreased sodium levels in the blood, which manifests as hyponatremia. This electrolyte imbalance is a typical finding in individuals experiencing gastrointestinal issues with fluid loss.

Choice A Reason:

The stoma bleeds lightly when touched is incorrect. Some minor bleeding during the initial postoperative period is expected due to surgical trauma. Light bleeding when touched might not be unusual in the immediate days following colostomy placement.

Choice B Reason:

The stoma appears dark in color is correct. A dark-colored stoma could indicate compromised blood supply or ischemia, which is a concerning finding postoperatively. It's crucial to report this change in color promptly to the provider for further evaluation and intervention.

Choice CReason:

The stoma is draining a small amount of liquid stool is incorrect. In the early postoperative period, drainage of liquid stool from the stoma is normal. The digestive system needs time to adapt to the new anatomy created by the colostomy, and initially, the stool consistency might be liquid before it starts to normalize.

Choice DReason:

The stoma protrudes slightly from the abdomen is incorrect. A slightly protruding stoma is a common and expected finding after colostomy surgery. It's often a normal part of the healing process as the stoma settles and adjusts.

Choice A Reason:

The stoma bleeds lightly when touched is incorrect. Some minor bleeding during the initial postoperative period is expected due to surgical trauma. Light bleeding when touched might not be unusual in the immediate days following colostomy placement.

Choice B Reason:

The stoma appears dark in color is correct. A dark-colored stoma could indicate compromised blood supply or ischemia, which is a concerning finding postoperatively. It's crucial to report this change in color promptly to the provider for further evaluation and intervention.

Choice CReason:

The stoma is draining a small amount of liquid stool is incorrect. In the early postoperative period, drainage of liquid stool from the stoma is normal. The digestive system needs time to adapt to the new anatomy created by the colostomy, and initially, the stool consistency might be liquid before it starts to normalize.

Choice DReason:

The stoma protrudes slightly from the abdomen is incorrect. A slightly protruding stoma is a common and expected finding after colostomy surgery. It's often a normal part of the healing process as the stoma settles and adjusts.

Choice A Reason:

Urinating after the specimen collection is incorrect. While it's important to ensure urine doesn't contaminate the stool specimen during collection, the instruction to urinate after the collection doesn't directly impact the collection process itself. The primary focus is on avoiding contamination of the stool sample with urine or toilet tissue during collection.

Choice B Reason:

Placing 1.3 cm (0.5 in) of formed stool into a culture tube is incorrect. The amount of stool needed for a specimen can vary based on the specific test requirements or laboratory instructions. A fixed measurement, like 1.3 cm of formed stool, might not accurately represent the necessary quantity for all types of stool tests. Specific instructions from the healthcare provider or laboratory should be followed for proper collection.

Choice C Reason:

Keeping the specimen in a warm area is incorrect. Stool specimens are typically collected and stored at room temperature unless otherwise specified by specific test instructions. Placing the specimen in a warm area could alter the characteristics of the sample or promote bacterial growth, potentially affecting test accuracy. The specimen should be handled according to the specific requirements outlined for the particular test.

Choice D Reason:

Avoid placing toilet tissue in the bedpan after defecation is correct. Placing toilet tissue in the bedpan after defecation can contaminate the stool specimen, affecting the accuracy of test results. It's important to collect the stool sample without any contamination from toilet tissue or urine.

Choice A Reason:

Including the family member in providing care for the client is incorrect. While involving the family in care might be helpful for some, not all family members might feel comfortable or capable of participating in direct care during such an emotional and difficult time. Asking their preferences and respecting their boundaries is crucial.

Choice B Reason:

Describing a personal experience with the death of a family member is incorrect. Sharing personal experiences could potentially be inappropriate or overwhelming for the family member. It might inadvertently shift the focus away from the client's needs and emotions.

Choice C Reason:

Asking if they have had prior experience with the death of a family member is correct. This approach allows the nurse to understand the family member's prior experiences with death, providing insights into their understanding, fears, and expectations. It also helps the nurse tailor their support accordingly, acknowledging their emotions and offering assistance that aligns with their comfort level.

Choice D Reason:

Suggesting that the family member contact a grief counselor is incorrect. While grief counseling might be beneficial, suggesting it immediately might not address the family member's immediate need or desire to help in the moment. It's essential to acknowledge their offer to help and offer immediate support or guidance that aligns with their comfort level.

Choice A Reason:

Stomach contents are yellowish-green in color is incorrect. While the color of stomach contents might indicate various aspects of digestion or bile presence, a yellowish-green color alone might not necessarily be an immediate cause for concern unless accompanied by other symptoms or indications of a problem.

Choice B Reason:

Aspirated stomach contents' pH measures 6.5 is incorrect. A pH of 6.5 in aspirated stomach contents might indicate a less acidic environment, but it's not usually considered significantly abnormal. However, it's still essential to consider the context and the individual client's situation when interpreting pH values.

Choice C Reason:

Residual volume of stomach contents measures 90 mL is correct. A residual volume of 90 mL is considered high and could indicate delayed gastric emptying or potential issues with the client's ability to tolerate or absorb feedings. Reporting this finding to the provider is essential for further assessment and potential adjustments in the client's care plan.

Choice D Reason:

Hyperactive bowel sounds are present is incorrect. Hyperactive bowel sounds might suggest increased peristalsis or bowel activity. While this finding may be noted and monitored, it might not require immediate reporting unless it's associated with other concerning symptoms or complications.

Choice A Reason:

Recheck the client's SaO2 level after having the client cough and clear their throat is correct. This action is crucial to ensure the accuracy of the SaO2 reading. Sometimes, minor obstructions or secretions in the airway can momentarily affect the oxygen saturation readings. Having the client cough and clear their throat may help improve the SaO2 readings by clearing any temporary blockages.

Choice B Reason:

Review the client's most recent SaO2 level in the medical record is incorrect. While reviewing the client's history is important, the immediate priority is to verify the current SaO2 level for accuracy before taking further action.

Choice C Reason:

Notify the charge nurse of the client's condition is incorrect. While it might eventually be necessary to inform other healthcare team members, the immediate action should focus on rechecking the SaO2 level to ensure the client's current oxygen saturation status.

Choice D Reason:

Check the client's medical records to see which medications were recently administered is incorrect. Knowing the client's recent medications is important for assessment, but it may not directly address the current situation of shortness of breath and low oxygen saturation. Rechecking the SaO2 level takes precedence in this acute situation.

Choice A Reason:

Measuring the intake and output of a client who has received furosemide is correct. This task involves recording and measuring fluid intake and output, which is typically within the scope of practice for assistive personnel. It requires accurate documentation and doesn't involve making clinical judgments.

Choice B Reason:

Reinforcing teaching with a client about crutch-gait walking is incorrect. Teaching and instructing clients about specific medical procedures or techniques usually require specialized knowledge and assessment skills, typically within the nurse's scope of practice.

Choice C Reason:

Checking a client's peripheral IV site for redness or swelling is incorrect. Assessing for redness or swelling at an IV site involves clinical judgment and assessment skills to identify potential complications. This task is better suited for a licensed nurse who can interpret findings and take appropriate action if needed.

Choice D Reason:

Assessing the pain level of a client who has received acetaminophen is incorrect. Assessing pain levels involves subjective interpretation and understanding of pain scales, which generally falls under the scope of licensed healthcare providers who can evaluate and manage pain interventions based on assessments.

Choice A Reason:

Removing 45 mL of urine from the catheter with a syringe is correct. To obtain a sterile urine specimen from an indwelling urinary catheter, the nurse should use a sterile syringe to aspirate a specific volume of urine from the catheter tubing. This method ensures minimal contamination and an accurate representation of the urine in the bladder at that moment.

Choice B Reason:

Clamping the catheter tubing for 60 min is incorrect.

Clamping the catheter tubing can lead to potential complications such as urinary retention, backflow of urine, or discomfort for the client. It's not a standard practice and could compromise the client's care.

Choice C Reason:

Clamping the catheter tubing below the needleless port is incorrect.

Clamping the catheter tubing can disrupt the urinary drainage and potentially cause issues like urinary stasis or increase the risk of infection. It's not an appropriate method for collecting a sterile urine specimen.

Choice D Reason:

Place the specimen in a clean specimen cup is incorrect. While placing the specimen in a clean cup is necessary, the method of collecting a urine sample from an indwelling catheter involves using a sterile syringe to aspirate a specific volume of urine directly from the catheter tubing, rather than pouring it into a cup from the collection bag.

Choice A Reason:

Deflate the cuff faster when repeating the BP measurement is incorrect.

The method of deflating the cuff faster is not a solution for accurately measuring blood pressure. It's essential to ensure proper technique and a standard approach to obtaining accurate readings.

Choice B Reason:

Measure the client's BP in the other arm is incorrect. While comparing blood pressure readings between arms can sometimes provide useful information, in this situation, the substantial increase in blood pressure is concerning and may need immediate attention rather than rechecking in another arm first.

Choice C Reason:

Use a narrower cuff to repeat the BP measurement is incorrect. Using an incorrectly sized cuff can lead to inaccurate blood pressure readings. However, the sudden significant increase in blood pressure is an urgent issue that requires attention and potential intervention rather than changing the cuff size for measurement.

Choice D Reason:

Request a prescription for an antihypertensive medication is correct. The significant increase in blood pressure warrants attention, and if it remains elevated and unexplained, it may require medical intervention to manage and prevent potential complications related to hypertension.

E. Disconnect the tube from the suction device:

Before starting the removal process, it's essential to disconnect the tube from any suction to prevent discomfort or injury to the client during removal.

C. Instill 50 mL of air into the tube:

Instilling air into the tube helps clear any residual contents and lubricates the tube, making it easier and more comfortable to remove.

B. Ask the client to take a deep breath:

Instructing the client to take a deep breath helps relax the throat and upper esophageal muscles, making the removal process smoother and potentially less uncomfortable.

D. Pinch and withdraw the tube:

Withdrawing the tube while the client holds their breath aids in a controlled removal, minimizing discomfort or risk of aspiration.

A. Apply clean gloves:

Lastly, applying clean gloves ensures infection control and maintains cleanliness during the removal process, preventing any potential contamination.

Choice A Reason:

Decreasing the volume on the hearing aid is correct. Whistling or feedback in a hearing aid can often occur due to excessive volume. Lowering the volume can help eliminate or reduce the whistling sound without disrupting the functioning of the hearing aid.

Choice B Reason:

Cleaning the hearing aid with isopropyl alcohol is incorrect. While cleaning the hearing aid is essential for maintenance, using isopropyl alcohol might not resolve the issue of whistling. It's more for general hygiene and cleanliness of the device.

Choice C Reason:

Turning the hearing aid off for 5 minutes is incorrect. Turning off the hearing aid might not address the specific issue of whistling. Additionally, it could inconvenience the client's ability to hear during that time.

Choice D Reason:

Soaking the hearing aid in warm water is incorrect. Soaking a hearing aid in water is not a recommended method, as it could damage the device and its electronic components. Water exposure might also worsen the issue instead of resolving it.

Choice A Reason :

Increased peripheral circulation is incorrect. As people age, changes in the cardiovascular system can occur, but increased peripheral circulation isn't a common physiological change. In fact, aging might lead to reduced elasticity in blood vessels, potentially resulting in decreased circulation to some areas.

Choice B Reason:

Increased saliva production is incorrect: Saliva production doesn't usually increase with age. Instead, certain medications, medical conditions, or treatments might impact saliva production. Aging itself doesn't commonly cause an increase in saliva production; in fact, it can decrease due to changes in salivary glands.

Choice C Reason:

Increased constipation is correct. As individuals age, there can be changes in gastrointestinal motility and muscle tone, which can contribute to an increased likelihood of constipation.

Choice D Reason:

Decreased muscle mass is correct. Aging often leads to a natural decline in muscle mass and strength, known as sarcopenia, which can affect mobility and overall physical function.

Choice E Reason:

Decreased cough reflex is correct. With aging, the cough reflex might become less sensitive or effective, which can impact the ability to clear the airways efficiently.

Choice AReason:

Encouraging the client to abstain from distracting activities is incorrect. Engaging in distracting activities can actually be beneficial in pain management. It can redirect the client's focus away from the pain, potentially reducing its intensity.

Choice BReason:

Ensuring that the client's room is kept at a cool temperature is incorrect.

While temperature can influence comfort, maintaining a cool room might not directly address or alleviate the client's pain.

Choice C Reason:

Playing music in the client's room is correct. Music therapy is a nonpharmacological intervention that can effectively help in managing pain. Calming or soothing music can distract the client from pain, reduce anxiety, and promote relaxation, potentially reducing the perception of pain.

Choice D Reason:

Keep the client's room well-lit is incorrect. The lighting in the room might not significantly impact pain levels. Some individuals might prefer dim lighting for relaxation, but it might not directly influence pain perception.

Choice A Reason:

Obtaining urine from the drainage bag if a urinary specimen is required is incorrect.

While obtaining urine from the drainage bag might seem practical for specimen collection, it's not the recommended method due to potential contamination of the specimen. A sterile sampling port or aspirating urine from the catheter tubing is a more appropriate technique.

Choice B Reason:

Using a catheter securing device to hold the catheter in place is correct. Securing the catheter with a proper securing device helps prevent unnecessary movement or tension on the catheter, reducing the risk of trauma to the urinary tract and ensuring stability for the catheter.

Choice C Reason:

Positioning the drainage bag higher than the client's bladder is incorrect. Positioning the drainage bag higher than the bladder can lead to backflow or reflux of urine, increasing the risk of urinary tract infections. The drainage bag should be placed below the level of the bladder to facilitate proper drainage.

Choice D Reason:

Changing the catheter bag every 3 days and as needed is incorrect. Routine changing of catheter bags every three days without clinical indication for changing can increase the risk of introducing infection. Catheter bags are changed based on clinical indications or when they are soiled or damaged, not on a fixed time schedule.

Choice A Reason:

Standing on the client's stronger side when moving the client into the chair is correct. This technique provides better support and stability during the transfer process. Standing on the stronger side allows the nurse to provide more assistance and better control while guiding the client into the chair.

Choice B Reason:

Pivot on the foot farthest from the bed when assisting the client into the chair is incorrect. While pivoting is essential during transfers, the choice of pivoting foot might vary depending on the specific transfer technique being used. However, it doesn't specifically address the client's left-sided weakness or provide direct assistance for the client's needs.

Choice C Reason:

Flexing hips and knees when assisting the client to a standing position is incorrect. Flexing the hips and knees helps maintain a stable base and reduce strain during the transfer. Although it's beneficial, it's a general technique and doesn't address the specific assistance needed for a client with left-sided weakness.

Choice D Reason:

Raising the bed to waist level before moving the client is incorrect. Adjusting the bed height is important for the comfort and safety of both the client and the nurse during transfers. However, it doesn't directly address the technique needed to assist a client with left-sided weakness during the transfer process.