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This statement is judgmental and discouraging. It implies that the client is not making enough effort and does not acknowledge the possible challenges or barriers that the client may face.

This statement is accusatory and confrontational. It puts the blame on the client and does not offer any support or guidance.

This statement is unrealistic and dismissive. It does not address the reasons for the weight gain and does not help the client learn from their experience. It also ignores the emotional impact of the setback.

This is an important action, but not the first one. The nurse should first address the client's comfort and inflammation before teaching them how to use the eye drops.

This is a helpful action, but not the first one. The nurse should first apply warm compresses to the affected eye, and then dim the lights to reduce the sensitivity and pain.

This is a necessary action, but not the first one. The nurse should first apply warm compresses to the affected eye, and then inspect the eyes for signs of infection or complications.

This is an incorrect action, because the nurse should apply sterile gloves when handling the bags of dialysate fluid to prevent infection.

This is an incorrect action, because the bags of dialysate fluid should be warmed to body temperature before instillation to prevent hypothermia and abdominal cramps.

This is an irrelevant action, because checking peripheral circulation of the client's arms has no relation to peritoneal dialysis, which involves the insertion of a catheter into the abdominal cavity.

This is a dangerous action, because recapping the needle on the syringe can increase the risk of needlestick injuries and bloodborne infections.

This is an unnecessary action, because the client may be able to self-administer insulin injections with proper education and supervision.

This is an inappropriate action, because the syringe should not be disposed of in the bathroom trash can, which is not a safe or sanitary place for sharps waste.

This is an incorrect intervention, because ambulating the client every 1 hr can increase the oxygen demand and worsen the sickling of the red blood cells.

This is an incorrect intervention, because applying cold compresses to painful joints can cause vasoconstriction and reduce the blood flow to the affected areas.

This is an incorrect intervention, because withholding opioids until the crisis is resolved can cause unnecessary suffering and increase the stress response, which can trigger more sickling.

This is a false statement, because adults do not receive a natural immunity to herpes zoster from casual exposure to children who have had chickenpox. Herpes zoster is caused by the reactivation of the varicella-zoster virus, which remains dormant in the nerve cells after a primary infection with chickenpox.

This is a false statement, because herpes zoster is not prevented by the MMR vaccine, which protects against measles, mumps, and rubella. Herpes zoster is prevented by the varicella vaccine, which is given separately from the MMR vaccine.

This is a false statement, because a client who has herpes zoster is contagious if blisters are present on the skin. The blisters contain the varicella-zoster virus, which can be transmitted through direct contact or airborne droplets.

This is an important data, but not the first one. The nurse should first assess the client's airway, breathing, and circulation, which are the priorities in any emergency situation.

This is a relevant data, but not the first one. The nurse should collect the presence of bowel sounds later, after ensuring the client's airway, breathing, and circulation are stable, to assess the client's gastrointestinal function and possible paralytic ileus.

This is a significant data, but not the first one. The nurse should collect the level of pain later, after ensuring the client's airway, breathing, and circulation are stable, to provide adequate analgesia and comfort measures.

This is a normal finding, not an indication of breast cancer. Lumps that are mobile and tender upon palpation prior to a menstrual period are usually benign and related to hormonal changes.

This is a normal finding, not an indication of breast cancer. Multiple round masses that are tender and found in both breasts are usually benign and related to fibrocystic breast changes.

This is a normal finding, not an indication of breast cancer. Bilaterally darkened areolas are usually benign and related to genetic factors, pregnancy, or aging.

This is an incorrect meal selection, because shrimp and rice are high in cholesterol and refined carbohydrates, which can increase the blood cholesterol and glucose levels.

This is an incorrect meal selection, because cheese omelet and turkey bacon are high in cholesterol and sodium, which can raise the blood pressure and worsen the cardiac function.

This is an incorrect meal selection, because liver and onions are high in cholesterol and iron, which can contribute to the formation of plaque and clots in the arteries.

This is an incorrect intervention, because obtaining a rectal temperature once per shift can cause trauma and bleeding in the rectal mucosa, which is highly vascularized and sensitive.

This is an unnecessary intervention, because the client who has thrombocytopenia does not have an increased risk of infection, unless they also have neutropenia or immunosuppression. The client should be allowed to have visitors, as long as they follow the infection control precautions.

This is an incorrect intervention, because encouraging daily flossing between teeth can cause gingival bleeding and ulceration in the client who has low platelet count and impaired clotting. The client should use a soft toothbrush and avoid dental floss.

This is an incorrect action, because emptying the drainage container every 4 hr is not necessary and can interfere with the accurate measurement of the drainage volume. The drainage container should be emptied only when it is full or at the end of the shift.

This is an incorrect action, because changing the client's insertion-site dressing each shift can increase the risk of infection and dislodgment of the chest tube. The insertion-site dressing should be changed only when it is soiled or loose.

This is an incorrect action, because clamping the chest tube when the client is ambulating can cause a tension pneumothorax, which is a life-threatening complication of chest tube insertion. The chest tube should be clamped only when ordered by the provider or when changing the drainage system.

This is an incorrect action, because covering the insertion site with a hydrocolloid dressing can prevent air from escaping and cause a subcutaneous emphysema, which is a complication of chest tube removal. The insertion site should be covered with a sterile gauze dressing and taped on three sides.

This is an important action, but not the first one. The nurse should provide pain medication before removal, not immediately after, to reduce the discomfort and anxiety of the client.

This is an incorrect action, because delegating removal of the chest tube to an AP is beyond the scope of practice and can cause harm to the client. The removal of the chest tube should be performed by the nurse or the provider.

This is an irrelevant data, because pupillary reaction to light has no relation to the client's condition, which is likely DKA. Pupillary reaction to light can help assess the client's neurological status and possible brain injury.

This is an irrelevant data, because deep tendon reflexes have no relation to the client's condition, which is likely DKA. Deep tendon reflexes can help assess the client's neuromuscular function and possible spinal cord injury.

This is a relevant data, but not the first one. Liver function laboratory values can help assess the client's hepatic function and possible liver damage, which can be a complication of DKA. However, blood glucose using a glucometer is more urgent and specific for the diagnosis and management of DKA.

This is an incorrect action, because elevating the residual limb on a soft pillow can cause contractures and impair the blood flow to the stump. The residual limb should be elevated only for the first 24 hr after surgery, and then positioned flat on the bed.

This is an incorrect action, because reapplying a bandage to the residual limb every 12 hr can increase the risk of infection and delay the healing of the wound. The bandage should be changed only when it is soiled or loose, and under sterile technique.

This is an incorrect action, because applying dressings to the site in a proximal-to-distal direction can cause edema and impair the circulation to

This is an incorrect route, because maternal-fetal transmission of hepatitis A is very rare and occurs only if the mother has acute hepatitis A during the third trimester of pregnancy.

This is an incorrect route, because genital sexual contact of hepatitis A is uncommon and occurs only if there is oral-anal contact with an infected person.

This is an incorrect route, because blood to blood transmission of hepatitis A is also uncommon and occurs only if there is exposure to infected blood or blood products, such as through needle sharing or transfusion.

This is an incorrect instruction, because it is not necessary to take this medication for the rest of your life to prevent recurrence. Isoniazid is usually taken for 6 to 9 months, or as prescribed by the provider, to treat active TB or latent TB infection.

This is an incorrect instruction, because you should avoid alcohol intake while you are taking this medication. Alcohol can increase the risk of hepatotoxicity and interfere with the metabolism of isoniazid.

This is an incorrect instruction, because it is not recommended to take this medication with a meal to increase absorption. Isoniazid should be taken on an empty stomach, at least 1 hour before or 2 hours after a meal, to ensure optimal absorption and effectiveness.

This is a correct statement, because the stool consistency depends on the location of the colostomy. A sigmoid colostomy is located in the lower part of the colon, where most of the water is absorbed, so the stool will be formed.

This is a correct statement, because the stoma size will decrease as the swelling subsides and the wound heals. The stoma will reach its final size in about 6 to 8 weeks after surgery.

This is a correct statement, because the colostomy function will resume gradually after surgery, depending on the bowel motility and the presence of gas or stool. The colostomy will usually start to function 2 to 6 days after surgery.

This is an incorrect finding, because Kussmaul respirations are a sign of diabetic ketoacidosis (DKA), which is a complication of type 1 diabetes mellitus that occurs when the blood glucose is too high, not too low. Kussmaul respirations are deep and rapid breathing that help the body eliminate excess carbon dioxide and acid.

This is an incorrect finding, because decreased skin turgor is a sign of dehydration, which is a complication of type 1 diabetes mellitus that occurs when the blood glucose is too high, not too low. Decreased skin turgor is a loss of elasticity and firmness of the skin that results from the loss of fluid and electrolytes through the urine and the skin.

This is an incorrect finding, because ketonuria is a sign of diabetic ketoacidosis (DKA), which is a complication of type 1 diabetes mellitus that occurs when the blood glucose is too high, not too low. Ketonuria is the presence of ketones in the urine, which are acidic substances that are produced when the body breaks down fat for energy due to the lack of insulin.

This is an incorrect imbalance, because metabolic acidosis is a condition that occurs when the blood pH is low, the PaCO2 is normal or low, and the HCO3 is low. Metabolic acidosis is caused by the accumulation of acids in the blood, which can result from diabetic ketoacidosis, renal failure, or lactic acidosis.

This is an incorrect imbalance, because respiratory acidosis is a condition that occurs when the blood pH is low, the PaCO2 is high, and the HCO3 is normal or high. Respiratory acidosis is caused by hypoventilation, which can result from airway obstruction, chest injury, or narcotic overdose.

This is an incorrect imbalance, because metabolic alkalosis is a condition that occurs when the blood pH is high, the PaCO2 is normal or high, and the HCO3 is high. Metabolic alkalosis is caused by the loss of acids from the blood, which can result from vomiting, gastric suction, or diuretic therapy.

This is an important action, but not the first one. The nurse should obtain the prescribed irrigation solution after assessing the client's pain level and providing analgesia if needed.

This is an important action, but not the first one. The nurse should don personal protective equipment after assessing the client's pain level and providing analgesia if needed.

This is an important action, but not the first one. The nurse should place a waterproof pad under the client's extremity after assessing the client's pain level and providing analgesia if needed.

This is an incorrect action, because instructing the client to blink several times after instillation of the medication can cause the medication to drain out of the eye and reduce its effectiveness.

This is a correct action, but not the best one. Asking the client to look straight ahead during instillation of the medication can help the nurse to aim the drop accurately and avoid touching the eye with the dropper.

This is an incorrect action, because placing each drop of the medication directly on to the client's cornea can cause irritation, injury, or infection to the eye. The medication should be placed in the lower conjunctival sac of the eye.

This is an important action, but not the first one. The nurse should provide oxygen after lowering the client to the floor and protecting the head, to improve the oxygenation and prevent hypoxia.

This is an important action, but not the first one. The nurse should turn the client onto his side after lowering the client to the floor and protecting the head, to prevent aspiration and maintain a patent airway.

This is a helpful action, but not the first one. The nurse should provide privacy after lowering the client to the floor and protecting the head, to respect the client's dignity and reduce the stimulation.

This is an incorrect information, because limiting fluid intake to 1,500 ml per day can cause dehydration and thickening of the respiratory secretions, which can impair gas exchange and increase the risk of infection.

This is an incorrect information, because practicing chest breathing each day can worsen gas exchange by increasing the use of accessory muscles, decreasing the diaphragmatic excursion, and reducing the lung expansion.

This is an incorrect information, because wearing home oxygen to maintain an SpO2 of at least 94% can be harmful for a client who has emphysema, as it can suppress the hypoxic drive and cause carbon dioxide retention, which can lead to respiratory acidosis and coma. The client who has emphysema should wear home oxygen to maintain an SpO2 of 88% to 92%, or as prescribed by the provider.

This is an incorrect statement, because the client still needs to take the antihypertensive medications as prescribed, even with a pacemaker. The pacemaker regulates the heart rate, but does not control the blood pressure, which can be affected by other factors, such as stress, diet, or kidney function.

This is an incorrect statement, because the client should avoid stretching the arms above the head for the first few weeks after the pacemaker insertion, as it can cause dislodgment or damage to the pacemaker leads. The client should limit the arm movements and activities until the incision site heals and the provider approves.

This is an incorrect statement, because the client can stand in front of a microwave oven without any risk, as long as the oven is in good working condition and does not leak radiation. The modern microwave ovens and pacemakers are designed to prevent any interference or damage. However, the client should avoid close contact with other sources of electromagnetic fields, such as metal detectors, cell phones, or MRI machines.

This is a vague and unhelpful response, because it does not provide any information or reassurance to the client who has a new diagnosis of MS. The nurse should explain the general course of MS and the possible variations among clients.

This is a sympathetic but incomplete response, because it does not address the client's question or provide any information about the course of MS. The nurse should acknowledge the client's feelings and provide factual and realistic information.

This is a dismissive and unrealistic response, because it does not answer the client's question or respect the client's right to know about the course of MS. The nurse should not avoid the client's concerns or minimize the impact of the diagnosis. The nurse should help the client cope with the uncertainty and plan for the future.