Cyanosis of the lips and nail beds

Rationale: Cyanosis of the lips and nail beds indicates severe hypoxia and requires immediate intervention. The nurse should report this finding to the provider and administer oxygen as prescribed.

Incorrect options:

A) Barrel-shaped chest - This is a common finding in clients with COPD, due to the increased anteroposterior diameter of the chest caused by air trapping and hyperinflation of the lungs. It does not require immediate intervention.

B) Clubbing of the fingers - This is a sign of chronic hypoxia and is often seen in clients with COPD. It results from the proliferation of connective tissue at the base of the nails due to chronic low oxygen levels. It does not require immediate intervention.

D) Wheezes on auscultation - This is an expected finding in clients with COPD, due to the narrowing of the airways caused by inflammation, mucus production, and bronchospasm. It does not require immediate intervention.

Nuchal rigidity

Rationale: Nuchal rigidity, or stiffness of the neck, is a classic sign of meningitis and indicates inflammation of the meninges, the membranes that cover the brain and spinal cord. Kernig's sign is a test that involves flexing the client's hip and knee at 90 degrees and then attempting to straighten the leg. A positive Kernig's sign is when the client experiences pain or resistance in the hamstring muscles, indicating meningeal irritation.

Incorrect options:

A) Fever - This is a nonspecific sign of infection and inflammation and does not indicate meningitis specifically.

B) Headache - This is a common symptom of meningitis, due to the increased intracranial pressure caused by inflammation of the meninges. However, it is not a specific sign that warrants performing a Kernig's sign test.

D) Photophobia - This is a common symptom of meningitis, due to the sensitivity of the optic nerve to light caused by inflammation of the meninges. However, it is not a specific sign that warrants performing a Kernig's sign test.

All of the above

Rationale: The nurse should document all aspects of wound care, including the type and amount of dressing used, the location and size of the wound, and the appearance and odor of the wound. This information helps to monitor the healing process, evaluate the effectiveness of interventions, and identify any signs of infection or complications.

Incorrect options:

A) The type and amount of dressing used - This is an important information to document, but not the only one.

B) The location and size of the wound - This is an important information to document, but not the only one.

C) The appearance and odor of the wound - This is an important information to document, but not the only one.

To prevent lactic acidosis due to contrast dye

Rationale: Metformin is an oral antidiabetic agent that lowers blood glucose levels by decreasing hepatic glucose production and increasing peripheral glucose uptake. However, metformin can cause lactic acidosis, a rare but serious condition that occurs when lactate accumulates in the blood faster than it can be metabolized. Lactic acidosis can be triggered by contrast dye used for radiographic procedures, such as colonoscopy, especially in clients who have renal impairment or dehydration. Therefore, metformin should be discontinued 48 hours before and after any procedure that involves contrast dye.

Incorrect options:

A) To prevent hypoglycemia during fasting - This is not the rationale for discontinuing metformin, as metformin does not cause hypoglycemia by itself. However, the client may need to adjust the dose of other antidiabetic medications or insulin to prevent hypoglycemia during fasting.

C) To prevent hyperglycemia due to stress response - This is not the rationale for discontinuing metformin, as metformin does not cause hyperglycemia by itself. However, the client may need to monitor blood glucose levels more frequently and report any signs of hyperglycemia to the provider.

D) To prevent nephrotoxicity due to dehydration - This is not the rationale for discontinuing metformin, as metformin does not cause nephrotoxicity by itself. However, the client should be advised to maintain adequate hydration before and after the procedure to prevent dehydration and renal impairment.

An air leak in the system

Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the system, which can compromise the negative pressure needed for effective drainage of air and fluid from the pleural space. The nurse should locate the source of the air leak and take appropriate measures to correct it. Possible sources of air leak include loose connections, cracks or holes in the tubing or drainage container, or a leak in the lung tissue.

Incorrect options:

B) A normal functioning of the system - Intermittent bubbling in the water seal chamber during inspiration, expiration, or coughing is a normal finding that indicates that air is being removed from the pleural space. Continuous bubbling is abnormal and indicates an air leak.

C) A need to empty the collection chamber - The collection chamber is where fluid drained from the pleural space accumulates. The nurse should empty the collection chamber when it is full or according to facility policy. Bubbling in the collection chamber is not a normal finding and does not indicate a need to empty it.

D) A need to clamp the chest tube - Clamping the chest tube is not recommended unless ordered by the provider or necessary for changing the drainage system. Clamping the chest tube can cause a buildup of pressure in the pleural space and lead to complications such as tension pneumothorax.

"I will avoid foods that are high in calcium."

Rationale: Hydrochlorothiazide is a thiazide diuretic that lowers blood pressure by increasing urine output and reducing fluid volume. However, it also causes increased excretion of potassium and magnesium, and decreased excretion of calcium and uric acid. Therefore, clients taking hydrochlorothiazide should eat more foods that are rich in potassium and magnesium, such as bananas, oranges, potatoes, spinach, nuts, and seeds; limit their intake of sodium and fluids to prevent fluid retention and edema; avoid foods that are high in uric acid, such as organ meats, shellfish, and alcohol; and monitor their serum calcium levels regularly. There is no need to avoid foods that are high in calcium, as hydrochlorothiazide does not increase calcium excretion.

Incorrect options:

A) "I will eat more foods that are rich in potassium." - This is a correct statement, as hydrochlorothiazide causes increased potassium excretion and can lead to hypokalemia if not supplemented.

B) "I will limit my intake of sodium and fluids." - This is a correct statement, as sodium and fluids can cause fluid retention and edema, which can increase blood pressure and counteract the effects of hydrochlorothiazide.

D) "I will drink alcohol in moderation." - This is a correct statement, as alcohol can increase uric acid levels and cause gout attacks in clients taking hydrochlorothiazide. Alcohol can also lower blood pressure and increase the risk of orthostatic hypotension.

Document the error in the client's medical record and the incident report.

Rationale: The nurse should document the error in both the client's medical record and the incident report, as this is part of the legal and ethical responsibility of the nurse. The documentation should include the facts of what happened, what actions were taken, and the client's response.

Incorrect options:

B) Notify the client's physician and the risk management department. - This is not the most appropriate action, as the nurse should first report the error to the nurse manager, who will then decide who else needs to be notified and how to proceed with further investigation and follow-up.

C) Explain the error to the client and apologize sincerely. - This is not the most appropriate action, as the nurse should first ensure that the client is safe and stable, and then consult with the nurse manager and the legal department before disclosing the error to the client. The nurse should also avoid admitting fault or liability, as this could have legal implications.

D) Wait until the end of the shift to report the error. - This is not an appropriate action, as the nurse should report the error as soon as possible, preferably within an hour of its occurrence. Delaying reporting could compromise client safety and quality of care, as well as increase the risk of legal action.

The client's functional status, goals, and discharge plan.

Rationale: The client's functional status, goals, and discharge plan are relevant information for the rehabilitation nurse, as they provide a baseline for assessing progress and planning interventions. The rehabilitation nurse will focus on helping the client regain function and independence, as well as preparing for discharge.

Incorrect options:

A) The client's vital signs, laboratory results, and medications. - This is not relevant information for the rehabilitation nurse, as these are routine data that can be obtained from other sources, such as electronic records or charts. The rehabilitation nurse will monitor these parameters as needed, but they are not essential for planning care.

B) The client's medical history, diagnosis, and prognosis. - This is not relevant information for the rehabilitation nurse, as these are general data that can be obtained from other sources, such as electronic records or charts. The rehabilitation nurse will be aware of these factors, but they are not specific for planning care.

D) The client's preferences, family involvement, and psychosocial needs. - This is not relevant information for the rehabilitation nurse, as these are subjective data that can be obtained from direct communication with the client and family. The rehabilitation nurse will address these aspects as part of holistic care, but they are not critical for planning care.

Repeat back the order to the physician verbatim.

Rationale: The nurse should repeat back the order to the physician verbatim, as this is a standard practice to verify the accuracy and completeness of the order. Repeating back the order allows the nurse and the physician to check for any errors, omissions, or ambiguities, and to clarify any questions or concerns.

Incorrect options:

B) Ask another nurse to listen to the order on speakerphone. - This is not an appropriate action, as it violates the confidentiality and privacy of the client and the physician. Moreover, it does not ensure that the order is correctly understood and recorded by the nurse who will enter it into the computer.

C) Writing down the order on a piece of paper before entering it into the computer is not an appropriate action as it increases the risk of transcription errors, lost or misplaced orders, or delayed entry. The nurse should enter the order directly into the computer as soon as possible and discard any paper notes after verification.

D) Confirming the order with a pharmacist before administering it to the client is not an appropriate action as it adds an unnecessary step and delays the implementation of the order. The nurse should confirm the order with the physician, not the pharmacist, and administer it to the client according to the prescribed schedule. The pharmacist will review the order for any potential interactions, allergies, or contraindications and alert the nurse if any issues arise.