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Confronting the nurse immediately without objective evidence can lead to defensiveness, denial, or legal complications. Managers must avoid premature confrontation because it lacks the foundation of documented proof and may compromise the integrity of the investigation.

Asking the nurse to sign an action plan assumes guilt before evidence is collected. This step is appropriate only after data has been gathered and a formal process initiated. Implementing corrective measures prematurely undermines fairness and due process.

Documentation is essential but should follow systematic data collection. Recording suspicious behavior without first gathering objective evidence risks bias and incomplete reporting. Documentation becomes meaningful only when supported by collected data.

Ambulation promotes peristalsis and reduces postoperative complications, but it should not be encouraged before assessing the underlying cause of nausea and pain. Without assessment, ambulation could worsen discomfort or mask complications.

Inserting an NG tube is an invasive intervention reserved for confirmed cases of bowel obstruction or severe ileus. Performing this without assessment risks unnecessary trauma and patient distress.

Administering an antiemetic addresses symptoms but not the underlying cause. Symptom relief without assessment could delay recognition of serious complications.

Moderate variability of the fetal heart rate is a reassuring sign of adequate oxygenation and intact neurological function. It is not an adverse effect.

Contractions every 2 minutes are within the normal therapeutic range for oxytocin augmentation. This frequency supports labor progression without compromising fetal well-being.

A fetal heart rate of 150/min is within the normal baseline range (110–160/min). This is not an adverse effect.

Extending the legs above heart level is not appropriate for dehiscence. This position does not reduce intra-abdominal pressure or protect the incision site.

The Valsalva maneuver increases intra-abdominal pressure, which would worsen dehiscence and potentially lead to evisceration. It is contraindicated.

Applying a dry gauze dressing does not provide adequate protection. A sterile, moist dressing is preferred to prevent tissue drying and reduce infection risk. Dry gauze could adhere to exposed tissue and cause trauma upon removal.

Cleansing the insertion site daily is not appropriate because frequent manipulation increases the risk of introducing pathogens into the epidural space. The site should be maintained with sterile technique and minimal disturbance to reduce infection risk.

Administering supplemental opioids without provider orders is unsafe. Epidural analgesia is tightly regulated, and additional opioids could increase the risk of respiratory depression, sedation, and overdose.

Replacing infusion tubing every 72 hours is standard for IV therapy but not specific to epidural analgesia. Epidural tubing requires specialized sterile handling and should not be routinely changed unless clinically indicated.

Clients do not need provider approval to sign advance directives. Advance directives are legal documents that reflect the client’s autonomy and do not require medical authorization.

Clients do not need to contact the court to change a living will. They can revise or revoke their advance directives at any time as long as they are competent to make decisions.

Clients are not required to designate a guardian to initiate advance directives. Guardianship is a legal process separate from advance directives and is not necessary unless the client has been deemed legally incompetent.

Arterial blood gases are not routinely required before initiating lithium therapy. They are more relevant in respiratory or metabolic disorders, not in baseline monitoring for lithium.

Total cholesterol is not directly affected by lithium therapy. While metabolic monitoring may be necessary for some psychiatric medications, cholesterol is not a priority baseline test for lithium.

Hemoglobin levels are not directly impacted by lithium therapy. While general health screening may include hemoglobin, it is not a priority baseline test specific to lithium administration.

Agnosia, the inability to recognize objects or people, is more commonly associated with neurocognitive disorders such as dementia rather than acute delirium. While delirium affects cognition, agnosia is not a typical finding.

Bradycardia is not a hallmark of delirium. Delirium is primarily a cognitive and perceptual disturbance, not a cardiac rhythm disorder. Bradycardia would suggest another underlying medical issue.

Aphasia, a language disturbance, is more characteristic of stroke or other focal neurological disorders. Delirium may cause disorganized speech due to confusion, but not true aphasia.

Incisional drainage positive for glucose indicates cerebrospinal fluid leakage, which is a complication, not an expected finding. This requires immediate intervention.

Drowsiness may occur but is concerning if excessive, as it can indicate shunt malfunction or increased intracranial pressure. It is not considered a normal expected finding.

Decreased head circumference is not expected immediately after shunt placement. Head growth should stabilize over time, but a sudden decrease would be abnormal.