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Clamp the tube for 30 min every 8 hr: Clamping a chest tube increases the risk of tension pneumothorax and is contraindicated unless ordered by a provider.

Pin the tubing to the client's bed sheets: Pinning can cause disconnection or kinking of the tubing, leading to drainage issues.

Monitor for at least 150 mL of drainage every hour: Drainage greater than 100 mL/hour, especially after the first hour, should be reported as it may indicate hemorrhage.

"It is common for the skin on my breasts to dimple": Dimpling can be a sign of breast cancer due to underlying tissue changes and should be evaluated.

"I will perform breast exams every other month": BSE should be done monthly to detect any changes early.

"I will perform breast exams the day my period begins": BSE should be done 5-7 days after the menstrual period starts when hormonal swelling has subsided.

Monitor the client for weight: Clonidine does not typically cause significant weight changes.

Check the client for increased hypopigmentation under the patch: Hypopigmentation is not a known side effect of clonidine patches.

Inform the client of the adverse effect of diarrhea: Clonidine more commonly causes constipation, not diarrhea.

Aspartate aminotransferase (AST) 34 units/L (0 to 34 units/L): This is within the normal range and does not contraindicate a biopsy.

Ammonia 55 mcg/dL (10 to 80 mcg/dL): This is within the normal range and does not directly impact the safety of a biopsy.

Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL): This is at the upper limit of normal and does not necessitate reporting in the context of a liver biopsy.

Hemorrhoidectomy is not likely to cause a false-positive test, as the wound would typically heal and stop bleeding after a year.

Citrus juice may alter the pH of the stool but is not a known cause of false-positive results in fecal occult blood tests.

Breast cancer is not directly associated with causing false-positive results in fecal occult blood tests.

Temperature 37.3° C (99.1° F): This temperature is within normal range and does not indicate an infection. Older adults may not always mount a fever with infections.

WBC count 9,000/mm³ (5,000 to 10,000/mm³): This is within the normal range, so it does not suggest infection. An elevated WBC count (>10,000/mm³) may indicate an infection.

Diminished reflexes: This is not a symptom of a bladder infection. It is more commonly associated with neurological or musculoskeletal conditions.

"My risk for a stroke increases if my HbA1c level is 5 percent or less.": An HbA1c level of 5% is excellent and indicates good glycemic control, which reduces stroke risk.

"Having a total cholesterol level below 200 mg/dL increases my risk for a stroke.": A cholesterol level below 200 mg/dL is desirable and lowers the risk of cardiovascular events, including stroke.

"My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke.": Glucocorticoids are not used to reduce stroke risk; they can actually increase blood sugar and cardiovascular risk if used long-term.

Instill saline into the tubing: Routine instillation of saline is not recommended as it can cause discomfort, dislodge bacteria, or create a risk of aspiration.

Increase the humidification: While humidification helps prevent mucus from becoming thick, it does not address the immediate issue of retained secretions causing crackles.

Check the cuff pressure: While it is important to ensure appropriate cuff pressure, this is not the primary intervention for resolving restlessness and crackles, which suggest secretion buildup.

"It is common for the skin on my breasts to dimple": Dimpling can be a sign of breast cancer due to underlying tissue changes and should be evaluated.

"I will perform breast exams every other month": BSE should be done monthly to detect any changes early.

"I will perform breast exams the day my period begins": BSE should be done 5-7 days after the menstrual period starts when hormonal swelling has subsided.

"Perform breast self-examinations during the middle of your cycle.": The best time for premenopausal clients to perform a breast self-exam is 5-7 days after the menstrual period ends, when hormonal fluctuations are minimal, and the breasts are less tender.

"Perform breast self-examinations while lying on your side.": The recommended position for self-examination is lying flat with the arm on the side being examined raised above the head, as this spreads the breast tissue more evenly.

"Use the palm of your hand to detect the presence of any large masses under the skin.": The pads of the fingers, not the palm, are used to palpate the breast for lumps or abnormalities.