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While it is important to provide support and reassurance to the client, simply encouraging them to continue with the scheduled surgery may not adequately address their specific concerns and fears. The charge nurse and the healthcare team should be involved to provide the necessary support and information to help alleviate the client's anxiety.

Documenting the client's concerns is important for accurate record-keeping and continuity of care. However, it should not be the only action taken. Notifying the charge nurse is crucial to ensure appropriate follow-up and support for the client.

Reminding the client that they have already signed the informed consent may not effectively address their fears and concerns. Reassurance and support should be provided, and involving the charge nurse and healthcare team is essential to address the client's emotional well-being.

This is not the correct answer because it does not address the parents' lack of information and understanding about hypospadias. While it is important to respect the parents' autonomy and decision- making, it is also the PN's responsibility to educate them about the benefits and risks of surgery, and to correct any misconceptions or myths they may have about hypospadias.

The PN should not be passive or indifferent about the parents' choice, but rather help them make an informed decision based on evidence- based practice.

This is not the correct answer because it is not true. Delaying surgery for hypospadias may increase the risk of complications such as infection, scarring, fistula formation, urethral stricture, curvature of the penis, and impaired sexual function.

The optimal timing for surgery depends on several factors, such as the severity of hypospadias, the child's age and health status, and the surgeon's preference, but it is generally recommended to perform surgery before 18 months of age¹². The PN should not give false reassurance or misinformation to the parents, but rather explain the potential consequences of postponing surgery.

This is not the correct answer because it is also not true. Hypospadias is a congenital condition that does not improve or disappear over time. Waiting for surgery may not be beneficial, but rather harmful, as it may increase the risk of complications and psychological distress for the child.

The PN should not give false hope or unrealistic expectations to the parents, but rather inform them about the nature and treatment of hypospadias.

This is not the correct answer because serum calcium is not directly related to nephrotoxicity. Serum calcium is the amount of calcium in the blood, which is important for bone health, muscle contraction, nerve function, and blood clotting. The normal range for serum calcium is 8.5 to 10.2 mg/dL. Serum calcium may be affected by kidney disease, but it is not a reliable indicator of nephrotoxicity.

This is not the correct answer because hemoglobin and hematocrit are not directly related to nephrotoxicity. Hemoglobin is the protein in red blood cells that carries oxygen, and hematocrit is the percentage of red blood cells in the blood. The normal range for hemoglobin is 13.5 to 17.5 g/dL for men and 12 to 15.5 g/dL for women, and for hematocrit is 38.8 to 50% for men and 34.9 to 44.5% for women.

This is not the correct answer because WBC is not directly related to nephrotoxicity. WBC is the number of white blood cells in the blood, which are part of the immune system and fight infections. The normal range for WBC is 4,500 to 10,000 cells per microliter of blood. WBC may be elevated in response to an infection or inflammation, but it is not a reliable indicator of nephrotoxicity.

Sacral edema is commonly associated with right-sided heart failure, not left-sided heart failure. While it is important to assess for edema in clients with heart failure, inspecting for sacral edema may not be the most immediate and crucial intervention in this specific case.

Measuring urinary output is a valuable assessment in many clinical situations, but it may not be the most vital intervention in the context of left-sided heart failure. Monitoring urinary output is more relevant in assessing kidney function and fluid balance rather than directly assessing the severity of left-sided heart failure.

Checking mental acuity is important in assessing the overall condition of the client, but it is not the most crucial intervention specifically related to left-sided heart failure. Mental status evaluation is more useful in identifying signs of altered mental status or potential complications, rather than directly assessing the impact of left-sided heart failure.

This is not the most important complication for the PN to anticipate because it is not directly related to burns. Elevated blood pressure, also known as hypertension, is a condition in which the force of blood against the artery walls is too high. It can be caused by various factors, such as genetics, lifestyle, medications, or underlying diseases.

The PN should monitor the blood pressure of a client with burns, as it may reflect changes in fluid status, pain level, or infection. However, elevated blood pressure is not a common or specific complication of burns.

This is not the most important complication for the PN to anticipate because it is more likely to occur in clients with full-thickness burns than partial-thickness burns. Compartment syndrome is a condition in which increased pressure within a closed space (such as a muscle or limb) compromises blood flow and tissue perfusion.

It can be caused by trauma, swelling, inflammation, infection, or tight dressings. The PN should assess for compartment syndrome in a client with burns, especially if the burn involves a circumferential area or an extremity. The PN should look for signs and symptoms of compartment syndrome, such as severe pain, pallor, paresthesia, paralysis, and pulselessness.

The PN should also loosen or remove any constrictive dressings or splints and notify the health care provider immediately if compartment syndrome is suspected.

This is not the most important complication for the PN to anticipate because it is not a complication but rather an expected outcome of burns. Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. It can be caused by various stimuli, such as heat, cold, pressure, or chemicals.

The PN should expect excruciating pain in a client who experienced partial-thickness burns over 30% of the BSA 3 days ago, as this type of burn involves damage to the epidermis and dermis layers of the skin, which contain many nerve endings. The PN should assess the pain level of the client using a valid and reliable pain scale and administer analgesics as prescribed by the health care provider.

The PN should also provide nonpharmacological interventions such as distraction, relaxation techniques, music therapy, or massage to help reduce pain.

This is not the correct answer because it is not related to ototoxicity. Vision is the ability to see and perceive objects and colors using the eyes and the brain. Vision may be affected by various factors, such as age, genetics, eye diseases, injuries, infections, or medications. However, aminoglycosides do not cause vision problems or impairments.

The PN should check for changes in vision in a client who is receiving other drugs that can cause ocular toxicity, such as ethambutol, chloroquine, or digoxin.

This is not the correct answer because it is not related to ototoxicity. A rash is a change in the color, texture, or appearance of the skin that may be caused by various factors, such as allergies, infections, inflammation, or medications. A rash may present as redness, itching, swelling, blisters, bumps, or scales.

Aminoglycosides can cause skin reactions such as rash or urticaria in some clients who are hypersensitive or allergic to them. The PN should observe the skin for a rash in a client who is receiving an aminoglycoside and report any signs of an allergic reaction to the health care provider. However, a rash is not a sign of ototoxicity.

This is not the correct answer because it is not related to ototoxicity. Urinary output is the amount of urine produced and excreted by the kidneys and bladder. It is an indicator of renal function and fluid balance. The normal range for urinary output is 0.5 to 1 mL/kg/hour for adults. Urinary output may be affected by various factors, such as fluid intake, dehydration, diuretics, kidney disease, or medications.

Aminoglycosides can cause nephrotoxicity, which is another potential adverse effect of these drugs. Nephrotoxicity is the damage or injury to the kidneys caused by certain drugs or chemicals. It can impair the kidneys' ability to filter waste products from the blood, resulting in reduced urine production and oliguria.

The PN should measure the urinary output in a client who is receiving an aminoglycoside and report any signs of nephrotoxicity to the health care provider. However, urinary output is not a sign of ototoxicity

This is not the priority action by the PN because it does not address the underlying cause of the client's symptoms. Drinking fluids can help maintain hydration and electrolyte balance in the body, which are important for normal functioning of cells and organs. However, it does not treat inflammation, infection, or allergy, which may be the reasons for the client's muscle soreness, fatigue, and warm skin. The PN should encourage the client to drink fluids only after reporting the findings to the charge nurse and obtaining an order from the health care provider.

This is not the priority action by the PN because it does not address the underlying cause of the client's symptoms. Drinking fluids can help maintain hydration and electrolyte balance in the body, which are important for normal functioning of cells and organs. However, it does not treat inflammation, infection, or allergy, which may be the reasons for the client's muscle soreness, fatigue, and warm skin. The PN should encourage the client to drink fluids only after reporting the findings to the charge nurse and obtaining an order from the health care provider.

This is not the priority action by the PN because it is not related to the client's symptoms. Serum lipid levels are measures of fats and cholesterol in the blood, which are important for energy production, hormone synthesis, and cell membrane structure. However, they are not related to inflammation, infection, or allergy, which may be the reasons for the client's muscle soreness, fatigue, and warm skin. The PN should monitor the client's serum lipid levels only if they are prescribed a medication that can affect lipid metabolism, such as statins or fibrates.

This is not the correct answer because it is not a priority question to ask the client next. Asking about the client's intention to obey the voices can help the PN assess the risk of harm to self or others, which is an important aspect of safety. However, this question may also imply that the PN believes or validates the voices, which may reinforce the client's delusions or false beliefs. The PN should ask about the client's plan to obey the voices only after establishing rapport and trust with the client, and after assessing the nature and content of the voices.

This is not the correct answer because it is not a respectful question to ask the client next. Asking about the client's substance use can help the PN identify the possible causes of hallucinations, as some drugs such as LSD, psilocybin, or ketamine can induce hallucinogenic effects. However, this question may also sound accusatory or confrontational, which may offend or alienate the client. The PN should ask about the client's substance use in a sensitive and nonthreatening manner, and after obtaining informed consent and ensuring confidentiality.

This is not the correct answer because it is not a helpful question to ask the client next. Asking about the client's belief in the reality of the voices can help the PN assess the level of insight or awareness that the client has about their condition. However, this question may also challenge or invalidate the client's perception, which may cause defensiveness or resistance. The PN should avoid arguing or disagreeing with the client about their hallucinations, as this may damage the therapeutic relationship. The PN should acknowledge and accept the client's experience without endorsing or reinforcing it.

While accurate charting of temperatures is important, it is not the primary concern in this situation. The PN should first focus on assessing the UAP's temperature measurement technique before addressing charting skills.

Returning the thermometer for recalibration may be necessary if there is evidence or suspicion of a malfunctioning thermometer. However, before assuming that the thermometer is the issue, it is important to first observe how the UAP obtains temperatures to rule out any human error in the measurement process.

Demonstrating how to use the equipment may be beneficial, but it should not be the first action taken in this scenario. The PN should first observe the UAP's technique to identify any potential errors or issues in temperature measurement. Based on the observation, the PN can provide specific guidance and demonstrate the correct technique if necessary.

This response assumes that the client needs someone else present to address their refusal to look at the incision. While having another nurse present may be helpful for some clients, it is not the appropriate first response. Respecting the client's autonomy and providing support should be the initial approach.

This response may come across as directive and insensitive. It implies that the client must look at their incision as part of their recovery process, disregarding their feelings and personal choices. It is important to respect the client's autonomy and allow them to navigate their own healing journey at their own pace.

This response invalidates the client's feelings and assumes that their concerns about the incision are unfounded. It is essential to respect the client's emotions and validate their experience rather than dismissing or minimizing their concerns.