A. Every four hours:

Turning a client every four hours may not be frequent enough to prevent pressure ulcers, especially in individuals with physical limitations or recent surgical procedures.

B. Every hour:

Turning a client every hour might be too frequent for some patients, and it may disrupt their rest and sleep. The optimal frequency depends on the client's condition.

C. Every shift:

Turning a client every shift (which typically spans 8-12 hours) may not provide adequate prevention for pressure ulcers, especially if the client has limited mobility.

D. Every two hours:

Turning a client every two hours is a common practice to prevent pressure ulcers. This interval helps redistribute pressure on vulnerable areas, improving blood circulation and reducing the risk of skin breakdown.

A. Palpation:

Palpation involves using the hands to feel for tenderness, masses, or abnormalities in the abdomen. It is typically performed after auscultation. This helps prevent stimulating bowel activity before listening to bowel sounds.

B. The order does not matter:

In the context of abdominal assessment, the order does matter. Following a specific sequence, such as inspection, auscultation, palpation, and then percussion, is recommended to ensure a comprehensive and accurate assessment.

C. Auscultation:

Auscultation involves listening to bowel sounds using a stethoscope. It is the next step after inspection. Listening to bowel sounds before palpation helps avoid artificially stimulating bowel activity.

D. Percussion:

Percussion involves tapping the abdomen to assess for the presence of fluid or air. While less commonly performed in routine abdominal assessments, it is usually the last technique after inspection, auscultation, and palpation.

A. Report the injury to a nurse manager:

While reporting the incident is important, the immediate action to take is cleaning the affected area to minimize the risk of infection.

B. Wash the affected area with soap and water:

This is the immediate priority to reduce the risk of potential infection or transmission of any contaminants from the needlestick injury.

C. Report the needle stick to the infection control department:

Reporting the incident is essential, but it should follow the immediate step of cleaning the affected area to prevent infection.

D. Scrub the area with hand sanitizer for a full 2 minutes:

Hand sanitizer may not be as effective as soap and water in removing contaminants from a needlestick injury site. Washing with soap and water is more appropriate for cleaning the area.

A. Defining the legal scope of nursing practice:

The nurse practice act in each state defines the scope of practice for nurses, outlining what nurses can and cannot do within the legal boundaries of their profession. It specifies the duties, responsibilities, and limitations of nursing practice within that particular state.

B. Lobbying federal lawmakers to advance professional nursing:

While nursing organizations and associations may engage in lobbying efforts at the federal level, it's not a direct component of the state's nurse practice act.

C. Providing continuing education programs:

While states might require nurses to participate in continuing education for license renewal, the provision of continuing education programs itself is not a direct element of the nurse practice act.

D. Creating institutional policies for health care practices:

Institutional policies are typically developed by healthcare institutions or organizations and are separate from the state's nurse practice act.

A. Evaluation:

Both RNs and LPNs engage in the evaluation step of the nursing process. It involves assessing the effectiveness of the care plan and determining whether the desired outcomes have been achieved.

B. Analysis:

The analysis step involves a deeper level of critical thinking and problem-solving. It often includes a more comprehensive examination and interpretation of assessment data to develop the nursing diagnosis, a step that typically falls within the scope of practice for RNs.

C. Implementation:

Both RNs and LPNs are involved in implementing the care plan, which includes carrying out nursing interventions according to the established plan of care.

D. Planning:

Both RNs and LPNs participate in the planning phase, which involves setting goals, establishing priorities, and creating a care plan tailored to the patient's needs.

A. Droplet isolation:

Droplet isolation is used for diseases spread by respiratory droplets that are larger than those in airborne transmission. Examples include influenza and bacterial meningitis.

B. Enhanced contact isolation:

Enhanced contact precautions are implemented for patients known or suspected to be infected with pathogens that require additional control measures beyond standard precautions. This may include multi-drug resistant organisms.

C. Airborne isolation:

Airborne isolation is specifically used for diseases that are transmitted through small airborne particles that can remain suspended in the air for an extended period. Tuberculosis is one such example. The use of N95 respirators and negative pressure rooms is common for airborne precautions.

D. Neutropenic isolation:

Neutropenic precautions are implemented for patients with compromised immune systems, particularly those with low neutrophil counts. It involves measures to protect the patient from potential infections.

A. 20 bpm: This is twice the calculated rate, so it's significantly higher than observed.

B. 10 bpm: This matches closely with the calculated rate of approximately 10.23 breaths per minute.

The scenario describes the nurse counting the client's breaths starting from when the second hand of the clock was at 12 and ending just past 5, and the client completed 9 breaths during this time frame.

Counting Period:

From just past 12 to just past 5 on the clock, the time span is approximately 53 seconds.

Number of Breaths:

The client completed 9 breaths within this time frame.

Now, to calculate the respiratory rate:

Respiratory rate = (Number of breaths / Time in minutes)

Respiratory rate = (9 breaths / 0.88 minutes) (53 seconds converted to minutes)

After calculation, the respiratory rate is approximately 10.23 breaths per minute.

C. 09 bpm: This is a lower value than observed and doesn't align with the counted breaths.

D. 18 bpm: This is close to double the observed rate, which doesn't match with the counted breaths within the time frame.

A. Perform oral hygiene at least every 2 hours:

Regular oral care is essential to maintain oral health, prevent infections, and provide comfort. When a client is NPO, and especially if they are weak or drowsy, the nurse should perform oral care at least every 2 hours to keep the oral cavity moist, reduce the risk of infection, and provide comfort.

B. Client must be supine with the head of the bed below 30 degrees:

Keeping the head of the bed elevated to at least 30 degrees is important for preventing aspiration and promoting respiratory function. This position is not specific to oral care but is a general guideline for managing clients at risk for aspiration.

C. Use alcohol-based mouth rinse with oral swab:

Alcohol-based mouth rinses can be drying and may not be suitable for a client who is NPO, as they might contribute to further dryness of the oral mucosa. Non-alcohol-based mouth rinses or moistened oral swabs are often preferred.

D. Assist the client with oral care by brushing their teeth twice daily:

While regular oral care is important, the frequency of twice daily brushing may not be sufficient for a weak, drowsy client, especially if they are NPO. Oral care should be performed more frequently to maintain oral hygiene.

A. Wash the client’s face:

While washing the client's face might be part of general care, when specifically providing oral care for a client with dentures, the first step should be to don gloves to ensure infection control and safety.

B. Remove dentures:

Removing dentures may be a step in the oral care process, but it should come after donning gloves to maintain proper infection control measures.

C. Apply lubricant:

Applying lubricant might be necessary, especially if the client experiences dryness or discomfort, but it should follow the step of donning gloves.

D. Don gloves:

This is the first action because it is crucial to wear gloves before handling a client's dentures or engaging in any oral care procedures. Gloves protect both the nurse and the client from potential infections and ensure proper hygiene during care.

A. Do not let the patient know you are counting their respirations:

This is not directly related to obtaining vital signs and is not a critical factor for a patient with a low platelet count.

B. Let the patient rest for 5 minutes before you measure their blood pressure:

Allowing the patient to rest for a few minutes before measuring blood pressure is a good practice but may not be as critical as other considerations in a patient with a low platelet count.

C. Do not measure the patient’s temperature rectally:

Patients with low platelet counts are at an increased risk of bleeding. Rectal temperatures can be invasive and carry a risk of mucosal injury, making them less advisable in patients with bleeding risks.

D. Count the patient’s radial pulse for 30 seconds and multiply it by 2:

Counting the radial pulse is a suitable method for assessing heart rate in a patient at risk for bleeding. However, rectal temperature measurement should be avoided due to the risk of mucosal injury.