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Assist the client to a chair before making the bed: Moving the client to a chair may help with bed-making logistics but does not directly address the client’s immediate respiratory needs. Prioritizing respiratory support over convenience is more important in dyspneic clients.

Ask the client about his usual morning routine: Understanding a client’s routine can help personalize care but is not the most critical action when dyspnea is present. Ensuring that the client can safely tolerate activities without respiratory compromise takes priority.

Encourage the client to participate in the care: Encouragement is helpful for promoting independence but must be balanced carefully. Pushing a dyspneic client to participate too much could lead to fatigue and exacerbate respiratory symptoms

Deficit in diversional activity: While limited activity can impact emotional health, signs like restlessness and physical tension suggest an immediate physical problem rather than boredom or inactivity. Comfort issues must be addressed first before considering diversional needs.

Elevated blood pressure: Stroke patients are at risk for hypertension, but restlessness and shallow respirations alone do not directly indicate elevated blood pressure. Blood pressure may rise secondary to pain or distress, but comfort assessment is still the initial focus.

Change in blood glucose level: Blood glucose fluctuations can cause changes in mental status or energy levels, but the client’s symptoms of clenching teeth and shallow breathing more strongly point toward discomfort or pain rather than hypoglycemia or hyperglycemia.

Sacrum: The sacrum is a common site for pressure ulcers in a supine position, but once the client is turned onto the side, pressure shifts away from the sacrum to lateral body surfaces. It is not the most at-risk area in the new position.

Ischial tuberosities: The ischial tuberosities bear weight when sitting, not typically when lying in a lateral position. Therefore, they are less likely to be the first site to show erythema when turned onto the side.

Lateral malleolus: The lateral malleolus can be at risk when the lower legs rub against the bed, but it is a smaller surface area and would show signs later compared to larger, more pressure-exposed areas like the iliac crest.

Reassure the client that the supplement will soon relieve those symptoms: Symptoms like tingling and numbness are not expected side effects of potassium therapy. Reassurance without investigation could delay necessary medical treatment and worsen the client’s condition.

Explain that a calcium supplement may be necessary: Calcium supplementation is not the standard response to symptoms of potassium imbalance. Without a clear diagnosis, recommending additional supplements could complicate the clinical situation further.

Encourage the client to decrease the intake of dietary sodium: Although reducing sodium is generally beneficial for health, it does not address the acute issue of possible potassium imbalance causing neuromuscular symptoms. Immediate clinical evaluation takes priority.

Apply lotion to sacrum: Applying lotion may help with general skin hydration but does not directly address pressure relief, which is the primary intervention needed to prevent worsening of a stage one pressure injury.

Use wet-to-dry dressings daily: Wet-to-dry dressings are used for wounds with necrotic tissue that need debridement. A stage one pressure injury involves intact skin without an open wound, so such dressings are not appropriate.

Elevate head of bed 30 degrees: Elevating the head of the bed slightly can reduce aspiration risk but also increases pressure on the sacrum if maintained for long periods. Position changes are more critical to relieve sacral pressure.

Beef broth, or chicken broth: While broth provides fluids and some electrolytes, it is very low in calories and protein, making it insufficient alone for preventing impaired skin integrity in a client with reduced oral intake.

Fortified lowfat milk: Milk offers some protein and nutrients, but a specialized nutritional supplement is more calorie-dense and protein-rich, providing a more comprehensive solution for a client at risk for skin breakdown.

Apple or grapefruit juice: Fruit juices offer hydration and some vitamins but lack significant protein and calories. They are inadequate for maintaining skin integrity, especially when protein intake is a primary concern.

Beef broth, or chicken broth: While broth provides fluids and some electrolytes, it is very low in calories and protein, making it insufficient alone for preventing impaired skin integrity in a client with reduced oral intake.

Fortified lowfat milk: Milk offers some protein and nutrients, but a specialized nutritional supplement is more calorie-dense and protein-rich, providing a more comprehensive solution for a client at risk for skin breakdown.

Apple or grapefruit juice: Fruit juices offer hydration and some vitamins but lack significant protein and calories. They are inadequate for maintaining skin integrity, especially when protein intake is a primary concern.

Administer oxygen: Cyanosis of the lips and tongue indicates poor oxygen saturation and tissue hypoxia. Administering oxygen is the priority action to improve oxygen delivery and prevent respiratory compromise.

Ask about pain: While assessing pain is important, it is not the priority in the presence of cyanosis, which reflects a potentially life-threatening oxygenation issue requiring immediate intervention.

Provide mouth care: Mouth care is not urgent and does not address the underlying problem of hypoxia. It should be deferred until after the client’s oxygenation status is stabilized.

Standards of practice for practical nursing: While important for general nursing care, national or professional standards do not replace the specific legal requirements outlined by the state’s licensing authority, which directly govern what a PN can and cannot do.

Geriatric standards of care guidelines: Geriatric care guidelines help provide quality care for older adults but are not the first priority when ensuring lawful nursing practice across state lines. Legal requirements must be understood first.

The employing agency's procedure manuals: While agency policies are important for specific job performance, they must be aligned with the state's legal scope of practice. Knowing the legal boundaries first is crucial before following any workplace procedures.