Illness in one family member can affect the other family members. This is because family-centered nursing care recognizes that the family is the basic unit of society and that each member's health influences the whole family's health. Family-centered nursing care also involves collaborating with the family to provide care that meets their needs, preferences, and values.

Choice A is wrong because the nurse does not provide family-centered nursing care to avoid the client’s loneliness. Loneliness is a psychosocial need, not a physiologic one, and it can be addressed by other means than involving the family.

Choice B is wrong because the client’s compliance with medical instructions is not the primary goal of family-centered nursing care. Compliance is influenced by many factors, such as motivation, education, culture, and trust, and it may not always depend on the family’s involvement.

Choice C is wrong because the family’s willingness to listen to instructions is not the main reason for providing family-centered nursing care. The nurse should respect the family’s autonomy and decision-making, and not impose instructions that may conflict with their beliefs or values.

The client on Digitalis has a low potassium level of 3.0 mEq/L, below the normal range of 3.5-5.0 mEq/L. Low potassium levels can increase the risk of digitalis toxicity, which can cause nausea, abdominal discomfort, visual changes, and cardiac arrhythmias.

The nurse would instruct the client to eat foods high in potassium, such as cantaloupe, to prevent or correct hypokalemia.

Choice A. Asparagus is wrong because asparagus is a low-potassium food that contains only 202 mg of potassium per cup.

Eating asparagus would not help to raise the client’s potassium level.

Choice C. Blackberries are wrong because blackberries are also a low-potassium food that contains only 233 mg of potassium per cup.

Eating blackberries would not help to raise the client’s potassium level.

Choice D. Cucumbers is wrong because cucumbers are a very low-potassium food that contains only 76 mg of potassium per cup.

Eating cucumbers would not help to raise the client’s potassium level and may even lower it further.

This action would cause the nurse to intervene because it increases the risk of choking and aspiration for a client with dysphagia, which is difficulty swallowing. The nurse would instruct the UAP to feed the client small amounts of food slowly, allowing time for chewing and swallowing.

Choice A is wrong because offering thickened liquids is a safe practice for a client with dysphagia. Thickened liquids allow for easier swallowing and less choking, thus decreasing the chance of aspiration.

Choice B is wrong because placing the client in an upright position is also a safe practice for a client with dysphagia. This position helps prevent food from entering the airway and facilitates swallowing.

Choice D is wrong because allowing ample time between bites is another safe practice for a client with dysphagia. This helps the client avoid feeling rushed or overwhelmed and reduces the risk of aspiration.

This is because spinach and salads contain a lot of vitamin K, which can make warfarin less effective at preventing blood clots.

Vitamin K helps the blood to clot, so eating foods high in vitamin K can counteract the effect of warfarin.

Choice A is wrong because wheat bread and butter do not contain a lot of vitamin K and do not affect warfarin.

Choice B is wrong because mangoes and tomatoes do not contain a lot of vitamin K and do not affect warfarin.

Choice D is wrong because aged cheeses and wine do not contain a lot of vitamin K and do not affect warfarin.

It is important to keep a stable diet while taking warfarin and avoid sudden changes in the amount of vitamin K intake. Foods that are high in vitamin K include green leafy vegetables, chickpeas, liver, egg yolks, avocado, and olive oil.

These foods should be limited but not eliminated from the diet. Do not drink cranberry or grapefruit juice while taking warfarin as they can increase the risk of bleeding.

Face the client while speaking and ask them to verify understanding. This intervention would help the client to read the nurse’s lips and confirm the message.

It would also show respect and empathy for the client’s condition.

Choice A is wrong because using exaggerated mouth and hand movements when speaking can be distracting and insulting to the client.

It can also distort the words and make them harder to understand.

Choice C is wrong because standing in front of a light when speaking to the client can create glare and make it difficult for the client to see the nurse’s face.

Touching the client to be sure they know where you are can be startling and unnecessary if the client is not visually impaired.

Choice D is wrong because obtaining an interpreter for sign language is inappropriate unless the client knows sign language.

Not all hearing-impaired clients use sign language, and some may prefer other methods of communication.

A weak, rapid pulse indicates that the client is experiencing hypovolemia or low blood volume due to blood loss during surgery.

The nurse should recommend to the provider to administer intravenous fluids to restore the client’s circulating volume and improve their hemodynamic status.

Choice A is wrong because anticholinergics are drugs that block the action of acetylcholine, a neurotransmitter that stimulates the parasympathetic nervous system.

Anticholinergics can cause tachycardia, dry mouth, urinary retention, and blurred vision. They are not indicated for hypovolemia.

Choice B is wrong because urinary catheter placement is not a priority intervention for a client with hypovolemia.

Urinary catheterization can help monitor urine output and renal perfusion but does not address the underlying cause of low blood volume.

Choice C is wrong because beta blockers are drugs that block the action of epinephrine and norepinephrine, neurotransmitters that stimulate the sympathetic nervous system.

Beta-blockers can lower blood pressure, heart rate, and cardiac output.

They are not indicated for hypovolemia and can worsen the client’s condition.

To communicate this information using the SBAR tool, the nurse should follow these steps: Situation: Identify yourself, the client, and the problem.

For example: “I am (name), the nurse caring for (client name) in room (number).

I am calling because I am concerned that the client has developed hypovolemia after surgery.”

Background: Provide relevant and brief information related to the situation.

For example: “The client had a surgical procedure (name and type) at (time) today. They have lost (amount) of blood during and after surgery.

Their current vital signs are: blood pressure (value), pulse (value), respiratory rate (value), temperature (value), oxygen saturation (value).”

Assessment: Share your analysis and considerations of options. For

Remove gloves, wash hands, remove face shield, gown, mask, and wash hands again. This is because gloves are the most contaminated piece of PPE and should be removed first to avoid touching other parts of the body or environment with them. Washing hands after removing gloves is also important to reduce the risk of infection. Face shields, gowns, and masks should be removed in that order, as they are less contaminated than gloves and can be handled with clean hands. Washing hands again after removing all PPE is the final step to ensure hygiene.

Choice A is wrong because it does not include washing hands after removing gloves, which is a crucial step to prevent contamination. It also removes the gown before the gloves, which can cause the gown to touch the face or hair and contaminate them.

Choice B is wrong because it does not include washing hands between removing gloves and gown, which can transfer germs from the gloves to the gown and then to the face or hair when removing the face shield and mask.

Choice D is wrong because it does not include washing hands between removing gloves and gown, which can transfer germs from the gloves to the gown and then to the face or hair when removing the face shield and mask. It also removes the gown before the face shield, which can cause the gown to touch the face or hair and contaminate it.

Normal ranges for PPE removal are not applicable as different types of PPE may require different methods of removal. However, some general principles are to remove PPE in a way that minimizes contact with contaminated surfaces, perform hand hygiene frequently, and dispose of PPE properly.

These nursing interventions can help promote bowel movement and prevent constipation. According to, constipation is a common gastrointestinal symptom caused by various factors such as a low-fiber diet, inadequate fluid intake, decreased gastrointestinal motility, medication use, and insufficient activity.

Therefore, encouraging high-fiber food choices, increasing fluid intake to 2,000 mL per day, and encouraging ambulation several times daily are appropriate interventions to address these factors and improve bowel function.

These nursing interventions can help promote bowel movement and prevent constipation. According to, constipation is a common gastrointestinal symptom caused by various factors such as a low-fiber diet, inadequate fluid intake, decreased gastrointestinal motility, medication use, and insufficient activity.

Therefore, encouraging high-fiber food choices, increasing fluid intake to 2,000 mL per day, and encouraging ambulation several times daily are appropriate interventions to address these factors and improve bowel function.

Choice D is wrong because administering antacids as necessary per the bowel management program is not a nursing intervention for constipation.

Antacids are used to neutralize stomach acid and relieve heartburn or indigestion.

They do not have any effect on bowel movement or constipation. In fact, some antacids may cause constipation as a side effect.

Therefore, this intervention is not relevant to the plan of care for a client diagnosed with constipation.

What is your understanding of the situation?”. This is a therapeutic response because it respects the client’s autonomy and invites them to share their concerns and feelings about the surgery.

Choice A is wrong because it is authoritarian and dismissive of the client’s feelings. It does not acknowledge the client’s right to refuse treatment.

Choice C is wrong because it is nontherapeutic and shows agreement with the client’s refusal. It also implies that the nurse and the doctor are on different sides.

Choice D is wrong because it is manipulative and guilt-tripping. It implies that the client does not care about their loved ones or their own life.

This is because the recovery position helps maintain the airway and prevent aspiration, and loosening the necktie prevents breathing restriction.

The other choices are wrong because:

Choice A is wrong because placing a stick or any object in the person’s mouth can cause injury to the teeth, gums, tongue or jaw and obstruct the airway. The person cannot swallow or bite their tongue during a seizure.

Choice B is wrong because recording the time of the seizure is not the first priority. The first priority is to ensure the safety and comfort of the person.

Choice C is wrong because restraining the limbs can cause injury or fracture, increase agitation and prolong the seizure. The nurse should protect the person from injury by moving furniture away and padding the head.

Normal ranges for seizure duration are usually less than 5 minutes for generalized tonic-clonic seizures and less than 15 seconds for absence seizures. If the seizure lasts longer than 5 minutes, or if the person has repeated seizures without regaining consciousness, it is considered a medical emergency and requires immediate treatment.