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

When a nurse forgets to document an event at the correct time, the best practice is to enter a late entry in the electronic health record (EHR). The late entry should be clearly labeled with the original time of occurrence to maintain accurate and legal documentation.

Choice D rationale

An addendum is used for adding additional details to a previously entered note, not for documenting a missed event. A late entry is preferred in this case.

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 MRSA4.

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 MRSA5.

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.