The correct answer is Choice A, Hot cocoa.

Choice A rationale:

Hot cocoa contains the least amount of caffeine among the options provided.A standard 240 mL (8 oz) cup of hot cocoa contains approximately 5 mg of caffeine. This is significantly less than the other beverages listed. Hot cocoa is made by adding cocoa powder and sugar or chocolate syrup to hot milk.The drink contains very little cacao, so the caffeine content is very low. Therefore, if a client is looking to reduce their dietary caffeine intake, hot cocoa would be a suitable choice.

Choice B rationale:

A cola soft drink contains more caffeine than hot cocoa.A standard 240 mL (8 oz) serving of a cola soft drink contains approximately 24-31 mg of caffeine. Cola is a popular flavor of soda around the world.Although the kola nut, from which the flavor of cola soda comes from, does naturally contain caffeine, the majority of the caffeine in cola is added by the manufacturer. Therefore, a cola soft drink would not be the best choice for a client looking to reduce their caffeine intake.

Choice C rationale:

Instant coffee contains even more caffeine.A standard 240 mL (8 oz) cup of instant coffee contains approximately 57-96 mg of caffeine.With instant coffee, caffeine measurements are based on the amount of the instant coffee powder used to make the drink. The caffeine content of coffee itself varies enormously.According to the USDA, 1 rounded teaspoon of instant coffee (1.8 grams in weight) contains 57 mg of caffeine.No matter how much water, milk, or creamer you add to the coffee - the amount of caffeine will remain the same. Therefore, instant coffee would not be a suitable choice for a client looking to reduce their caffeine intake.

Choice D rationale:

Brewed green tea also contains more caffeine than hot cocoa.An 8-ounce (240 mL) cup of green tea generally supplies around 20 to 45 milligrams of caffeine.This makes green tea a gentler alternative in terms of caffeine content, suitable for those who prefer a milder pick-me-up. However, it still contains more caffeine than hot cocoa. Therefore, while green tea is a healthier choice compared to cola soft drinks and instant coffee, it still contains more caffeine than hot cocoa.

A. Incorrect. A urine output of 300 ml over 8 hours is within the expected range for a postoperative client and does not require immediate reporting.
B. Incorrect. Occasional small clots in the urine are common in the immediate postoperative period following a transurethral resection of the prostate and do not necessarily require immediate reporting.
C. Correct. Dark red urine can indicate bleeding and may be a sign of hemorrhage. This finding should be reported to the provider for further assessment and intervention.
D. Incorrect. A frequent urge to urinate is expected following a transurethral resection of the prostate, as irritation and swelling can occur in the immediate postoperative period.

The correct answer is choice c. “I am thankful I am done having children.”

Choice A rationale: This statement is incorrect because a vaginal hysterectomy involves the removal of the uterus, which means the client will no longer have menstrual periods.

Choice B rationale: This statement is incorrect because even after a hysterectomy, regular gynecological examinations are still necessary to monitor the health of the remaining reproductive organs and overall health.

Choice C rationale: This statement indicates that the client understands the implications of the surgery, specifically that they will no longer be able to have children, which is a key aspect of informed consent for a hysterectomy.

Choice D rationale: This statement is incorrect because a vaginal hysterectomy does not involve an abdominal incision, so there will not be a large scar on the stomach. The procedure is performed through the vagina.

A. Incorrect. Opening the fireplace dampers may allow external contaminants to enter the facility and is not recommended during an external chemical disaster.
B. Incorrect. Covering electrical outlets with wet towels may not provide effective protection against chemical contaminants and is not a recommended action.
C. Correct. Moving clients to a room above ground with few windows helps protect them from potential exposure to external chemical contaminants. Windows can allow contaminants to enter, and an aboveground location can reduce the risk of exposure.
D. Incorrect. Turning on fans may circulate contaminated air throughout the facility and is not recommended during a chemical disaster.

A. Incorrect. Human papillomavirus (HPV. is a common sexually transmitted infection, but it is not typically a reportable infection to the state health department.
B. Correct. Neisseria gonorrhoeae is a reportable sexually transmitted infection, and healthcare providers are required to report cases to the state health department for tracking and intervention purposes.
C. Incorrect. Impetigo contagiosa is a bacterial skin infection, but it is not typically a reportable infection to the state health department.
D. Incorrect. Sarcoptes scabiei is the parasite that causes scabies, a skin condition, but it is not typically a reportable infection to the state health department.

A. Incorrect. Justice refers to fairness and equal treatment for all clients. It is not demonstrated in this scenario.
B. Correct. Fidelity, also known as "faithfulness" or "loyalty," refers to the nurse's commitment to keeping promises and maintaining trust with the client. By walking with the client as promised, the nurse is demonstrating fidelity.
C. Incorrect. Autonomy refers to the client's right to make decisions about their own care and treatment. While the nurse is respecting the client's autonomy by addressing their anxiety, the ethical principle being demonstrated here is fidelity.
D. Incorrect. Nonmaleficence refers to the duty to do no harm. While the nurse is indeed trying to prevent harm (anxiety. for the client, the ethical principle being demonstrated in this scenario is fidelity.

A. Incorrect. Elevating the arm might help reduce edema, but the priority is to stop the infusion to prevent further infiltration.
B. Incorrect. While documenting the infiltration is important, immediate action should be taken to stop the infusion to prevent further complications.
C. Correct. The nurse's first action should be to stop the infusion to prevent the continuation of fluid infiltration and potential complications.
D. Incorrect. Applying a warm compress might help with comfort, but stopping the infusion is the priority to prevent further infiltration.

A. Discarding worksheets containing client information in a wastebasket does not ensure proper disposal of confidential information and could compromise confidentiality.
B. Writing a client's diagnosis on the message board in the client's room could breach confidentiality, as it could potentially be seen by unauthorized individuals.
C. This action protects client confidentiality because it involves discussing sensitive information in a private setting where unauthorized individuals are less likely to overhear. This is an appropriate method of communicating client information during a handoff.
D. While sharing relevant information with personnel directly involved in the client's care is generally acceptable, it must still be done in a manner that safeguards confidentiality.

A. Incorrect. Placing the client in a supine position may impede drainage and is not recommended for a client with a chest tube.
B. Correct. Ensuring that the chest tube drainage system is kept below the level of the client's chest allows for proper drainage of fluid and prevents backflow of drainage into the client's chest.
C. Incorrect. The collection chamber should be emptied as needed to prevent overfilling, which could obstruct drainage.
D. Incorrect. Clamping the chest tube is not indicated for a client with a chest tube set to continuous suction, as it would interfere with the function of the drainage system.

A. Incorrect. The airbag should be turned off if an infant car seat is placed in the front seat, as airbags can pose a significant risk to infants.
B. Incorrect. The car seat should be positioned at a 45° angle to prevent the infant's head from falling forward and obstructing the airway.
C. Incorrect. Placing a small cushion under the newborn's head is not recommended, as it can interfere with proper positioning and safety in the car seat.
D. Correct. The shoulder harnesses of the car seat should be positioned at the level of the infant's shoulders to ensure proper fit and safety during travel.