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because aspirin should not be given to children or adolescents with viral infections, as it can cause Reye’s syndrome, a rare but potentially fatal condition that affects the liver and brain.

rubella does not require airborne precautions, which are used for diseases that can spread through very small droplets that can remain in the air for long periods of time, such as tuberculosis or measles. Rubella spreads through direct contact with saliva or mucus of an infected person, or through respiratory droplets from coughing or sneezing.

because Koplik spots are a characteristic sign of measles, not rubella.

Koplik spots are small white spots that appear on the inside of the cheeks before the measles rash develops. Rubella causes a pink or red rash that usually starts on the face and moves down the body.

Normal ranges for rubella antibody tests are:

• IgM: Negative or less than 0.9 IU/mL
• IgG: Negative or less than 10 IU/mL

A positive IgM result indicates a recent or current infection, while a positive IgG result indicates a past infection or immunity from vaccination.

Placing sterile gauze over areas of spilled solution is a step to manage any spills or contamination within the sterile field.

Holding the irrigation solution bottle with the label facing away from the palm of the hand is important to avoid contamination but is not directly related to pouring the solution.

Removing the cap and placing it sterile-side up on a clean surface is a crucial step in maintaining the sterility of the solution bottle and preventing contamination, but it is not about pouring the solution.

Schedule nursing staff training for infection control procedures: While training is important, it should be based on identified needs. Without first understanding the precipitating factors of the increased infections, the training may not address the actual issues at hand.

wrong because meeting with providers to discuss measures to decrease the infections is not the first action the nurse should take.

While it is important to collaborate with providers on strategies to prevent CAUTIs, such as limiting the use of catheters and prescribing appropriate antibiotics, this is not an urgent priority compared to educating the nursing staff on infection control procedures.

because revising the current policy for catheter care is not the first action the nurse should take.

While it is important to review and update the policy based on current evidence and guidelines, this is not an immediate intervention that will prevent further infections.

The nurse should first ensure that the nursing staff are following the existing policy and provide feedback and education as needed.

Creatine kinase (CK) test: While creatine kinase isoenzymes, including CK-MB, can be elevated following myocardial infarction (MI), they are not specific to cardiac muscle injury. CK is found in various tissues throughout the body, so elevated levels can also indicate damage to skeletal muscle or brain tissue, among other sources.

Creatine kinase-myocardial band (CK-MB) test: CK-MB is a cardiac-specific isoform of creatine kinase, and elevated levels can indicate myocardial injury, particularly in the context of an acute MI. However, troponin T is a more sensitive and specific marker for myocardial injury.

Brain natriuretic peptide (BNP) test: Brain natriuretic peptide is primarily used in the diagnosis and management of heart failure. While elevated BNP levels can indicate heart muscle strain or stress, they are not specific markers for acute myocardial infarction or early injury to the cardiac muscle.

wrong because placing a yellow bracelet on a client who is at risk for falls is not malpractice, but rather a safety measure.

A yellow bracelet indicates that the client needs assistance with mobility and should not be left alone. This is a common practice in many health care facilities to prevent falls and injuries.

wrong because leaving a nasogastric tube clamped after administering oral medication is not malpractice, but rather a mistake.

A nasogastric tube is a tube that goes through the nose and into the stomach to deliver nutrition or medication.

It should be unclamped after giving oral medication to allow the medication to enter the stomach and prevent reflux or aspiration. However, this error does not rise to the level of malpractice unless it causes harm to the patient, such as vomiting, choking, or infection.

because documenting communication with a provider in the progress notes of the client’s medical record is not malpractice, but rather a good practice. A nurse

decreasing insoluble fiber intake can worsen constipation.

Insoluble fiber adds bulk to the stool and helps it pass more easily through the colon.

Clients who take opioid medications should increase their intake of insoluble fiber from sources such as whole grains, fruits, vegetables, nuts, and seeds.

because drinking less water can lead to dehydration and hardening of the stool, which can make it more difficult to pass.

Clients who take opioid medications should drink plenty of water to keep the stool soft and moist.

is wrong because taking a laxative every day can cause dependence, tolerance, and electrolyte imbalance.

Laxatives should be used only as a last resort and under the guidance of a health care provider.

Clients who take opioid medications should try other methods of preventing constipation first, such as increasing exercise, fiber, and water intake.

because antitoxin is not used to treat Lyme disease.

Antitoxin is a substance that neutralizes the effects of a toxin, such as botulism or tetanus. Lyme disease is caused by a bacterium called Borrelia burgdorferi, which can be treated with antibiotics.

wrong because Lyme disease is not transmitted by sharing personal belongings. Lyme disease is spread to humans by the bite of infected ticks that carry the

bacterium. The risk of getting Lyme disease can be reduced by avoiding tick-infested areas, wearing protective clothing, using insect repellent, and removing ticks promptly.

is wrong because skin necrosis is not a common complication of Lyme disease.

Skin necrosis is the death of skin tissue due to lack of blood supply or infection. Lyme disease can cause a characteristic skin rash called erythema migrans, which is usually circular or oval and expands over time. Other possible signs and symptoms of Lyme disease include fever, headache, fatigue, joint pain, and neurological problems.

Use an incentive spirometer every 4 hours.” is wrong because it is not related to promoting circulation, but rather to improving lung expansion and preventing atelectasis and pneumonia. Using an incentive spirometer is also important for postoperative clients, but it does not address the question.

Remain on bed rest for 24 hours following the procedure.” is wrong because it is the opposite of promoting circulation.

Bed rest increases the risk of venous stasis, thrombosis, and pulmonary embolism. Postoperative clients should be encouraged to ambulate as soon as possible, unless contraindicated.

Place a pillow under your knees while in bed.” is wrong because it also impairs circulation and increases the risk of thrombosis.

Placing a pillow under the knees can cause pressure on the popliteal veins and reduce blood flow. Postoperative clients should avoid this position and keep their legs in a neutral or slightly elevated position

While discussing the client's behavior may be helpful in some situations, it is not the most appropriate action to take immediately before seclusion. This is because:

1. Escalation:Attempting to discuss behavior in the moments leading up to seclusion can potentially escalate the situation and further jeopardize the safety of the client,staff,and other patients.
2. Impaired Insight:Clients requiring seclusion may have limited ability to engage in rational discussion due to heightened emotional states,cognitive impairment,or acute mental illness.
3. Limited Receptiveness:The client may not be receptive to feedback or discussion while in a state of crisis,potentially leading to frustration and further agitation.

Offering fluids is a basic nursing intervention, but it is not the priority action in this scenario. The primary focus at this time is ensuring safety and managing the acute behavioral crisis. Addressing hydration needs can be attended to after the client is safely placed in seclusion.

Assess the client’s behavior once every hour.:

Regular assessment is crucial, but hourly assessment is not frequent enough in this situation. Clients in seclusion require close monitoring and assessment at more frequent intervals to ensure their safety and well-being, as well as to evaluate the effectiveness of the seclusion intervention.

Choice A is wrong because flushing the catheter with saline should be done after securing the catheter to the skin with a transparent dressing and attaching a primed piece of extension tubing to the catheter.

Choice B is wrong because retracting the stylet should be done after advancing the catheter into the vein and releasing the tourniquet from the client’s arm.

Choice C is wrong because releasing the tourniquet should be done after advancing the catheter into the vein and before retracting the stylet.