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Avoiding fresh flowers in the room is unnecessary for a child with Clostridium difficile. Fresh flowers are typically restricted for clients who are immunocompromised, such as those undergoing chemotherapy or organ transplants, rather than those with infectious diarrhea.

Using an N95 respirator is incorrect. Clostridium difficile is transmitted via the fecal-oral route and requires contact precautions, not airborne precautions. An N95 mask is only required for airborne pathogens like tuberculosis or measles.

Placing the child in a room with a HEPA filtration system is unnecessary. HEPA filtration is used for airborne pathogens, whereas Clostridium difficile is spread via direct and indirect contact rather than through the air.

Using patterned-paced breathing is typically associated with labor pain management rather than postoperative pain following a cesarean birth. While controlled breathing can help with discomfort, it is not the most effective strategy for incision-related pain.

Changing positions as little as possible is incorrect. Early mobility is encouraged after a cesarean birth to promote circulation, prevent complications like deep vein thrombosis, and aid recovery. Avoiding movement can lead to stiffness and prolonged discomfort.

Applying counterpressure to the back is incorrect. Counterpressure is a technique used for back labor pain during childbirth and is not relevant for post-cesarean incision pain.

Eating turkey sausage for breakfast is incorrect. Processed meats, including turkey sausage, are high in sodium and should be avoided in a low-sodium diet. Even "healthier" alternatives can contain significant amounts of added salt.

Putting ketchup on hot dogs is incorrect. Ketchup and hot dogs are both high in sodium, making them poor choices for a client managing hypertension.

Using store-bought spaghetti sauce is incorrect. Many commercial pasta sauces contain high levels of sodium, which can contribute to increased blood pressure. A low-sodium alternative, such as homemade sauce with fresh ingredients, would be a better choice.

An acute hemolytic reaction is incorrect. This reaction occurs when the recipient's immune system attacks incompatible donor red blood cells, leading to symptoms such as fever, chills, flank pain, hypotension, and hemoglobinuria. Urticaria and wheezing are not characteristic symptoms of this reaction.

A febrile reaction is incorrect. Febrile reactions are the most common type of transfusion reaction and are typically characterized by fever, chills, and headache, rather than urticaria or wheezing.

Circulatory overload is incorrect. This reaction occurs when too much fluid is infused too quickly, leading to dyspnea, hypertension, and pulmonary edema. While respiratory distress can occur, it is not accompanied by urticaria, which is specific to an allergic reaction.

Holding gentle, direct pressure on the protruding organ is incorrect. Applying pressure can cause further damage to the exposed tissue and increase the risk of complications. Instead, the focus should be on protecting the organs and minimizing contamination.

Placing the client’s knees in an extended position is incorrect. Keeping the knees straight can increase tension on the wound. Instead, the nurse should position the client with the knees slightly flexed to reduce strain on the abdominal incision.

Raising the head of the bed to a 45° angle is incorrect. A high Fowler’s position can increase pressure on the wound. The nurse should place the client in a low Fowler’s position (supine with knees slightly flexed. to reduce tension and prevent further protrusion.

Placing the cap over the needle is incorrect. Once insulin preparation has started, recapping the needle is unnecessary and increases the risk of contamination or needlestick injury.

Verifying the dosage with another nurse is incorrect at this stage. Dosage verification should be done after the correct amounts of insulin are drawn into the syringe, not before.

Withdrawing 10 units of NPH insulin is incorrect. The nurse should first withdraw the regular (clear) insulin before drawing up the NPH (cloudy) insulin to avoid contaminating the regular insulin with the longer-acting insulin.

Taking the newborn back to the nursery is incorrect. While rest is important for the mother, removing the baby does not help build her confidence or teach her how to respond to her infant’s needs. Supporting her in learning newborn care is more beneficial.

Turning the baby on his side to help him sleep is incorrect. The safest sleep position for a newborn is on the back, according to safe sleep guidelines. Additionally, this response does not address the mother's feelings of inadequacy.

Explaining that babies cry to develop their lungs is incorrect. While crying is normal for newborns, this response dismisses the client’s concern rather than providing reassurance and support.

Using written signs to assist with locating the bathroom is incorrect. While cues can be helpful, clients with Alzheimer's disease often experience difficulty processing written information as the disease progresses. Using pictures or symbols instead of words is more effective.

Providing a stimulating environment for the client is incorrect. An overly stimulating environment can increase agitation and confusion. A calm, structured setting with minimal distractions is better for clients with Alzheimer's disease.

Using confrontation to manage the client’s behavior is incorrect. Confronting or arguing with a client who has Alzheimer's disease can lead to increased agitation and distress. Instead, caregivers should use redirection and reassurance to manage behaviors effectively.

Turning the oxygen up to 10 when the client has trouble breathing is incorrect. Oxygen flow rates should be adjusted only as prescribed by the provider. Increasing the flow rate without guidance can lead to complications, such as oxygen toxicity in clients with chronic respiratory conditions.

Using petroleum jelly to keep the nares moist is incorrect. Petroleum-based products are flammable and should not be used with oxygen therapy. Instead, a water-based lubricant should be used to prevent nasal dryness.

Removing the nasal cannula when eating is incorrect. Clients using a nasal cannula can continue wearing it while eating, as it allows them to receive oxygen continuously. If needed, a healthcare provider can recommend adjustments to oxygen flow during meals.

Denial is incorrect. Denial involves refusing to acknowledge reality or a distressing situation, which is not evident in this scenario. The adolescent is aware of the conflict and has chosen a constructive way to address it.

Regression is incorrect. Regression occurs when an individual reverts to an earlier stage of development in response to stress. Examples include an older child suddenly sucking their thumb or having temper tantrums. The adolescent in this scenario is demonstrating maturity, not regression.

Repression is incorrect. Repression involves unconsciously blocking distressing thoughts or emotions from awareness. The adolescent is not avoiding or forgetting about the conflict but is instead managing it through physical activity.

Stating that palliative care is only for clients with a terminal illness is incorrect. Palliative care is designed for clients with serious, chronic, or life-threatening illnesses and focuses on symptom management and quality of life, regardless of prognosis.

Limiting palliative care to those with 6 months or less to live is incorrect. This definition applies to hospice care, not palliative care. Palliative care can be provided alongside curative treatments at any stage of illness.

Including restriction of nutritional support is incorrect. Palliative care emphasizes comfort and symptom relief, including providing adequate nutrition and hydration as appropriate for the client’s needs and wishes.

Exercising when insulin is at its peak action is incorrect. Exercising during peak insulin activity increases the risk of hypoglycemia. It is best to exercise when insulin levels are more stable, such as 1 to 2 hours after a meal.

Injecting additional insulin before exercising is incorrect. Exercise naturally lowers blood glucose, so adding extra insulin increases the risk of hypoglycemia. Instead, insulin doses may need to be adjusted downward based on activity levels.

Avoiding protein before exercising is incorrect. While carbohydrates are the primary concern, protein intake before exercise is not harmful and can support muscle function. However, the focus should be on carbohydrate intake to maintain blood glucose levels.

Carrying the baby to the nursery is incorrect. Most facilities require that newborns be transported in a bassinet, not carried, to reduce the risk of accidental drops or abductions.

Removing the security band to give to a family member is incorrect. The security band must remain on the mother at all times to verify identity when interacting with the baby. Removing it can compromise security.

Taking the baby to the lobby to visit family is incorrect. Many hospitals have strict policies requiring newborns to remain in designated areas for security and infection control reasons. Visitors should come to the mother’s room instead.

Referring to a physical therapist is incorrect. Physical therapists focus on improving mobility, strength, and balance, but they do not typically assist with transportation needs or alternative arrangements for follow-up appointments.

Referring to a primary care provider is incorrect. While the primary care provider oversees medical care and follow-ups, they do not arrange transportation services or address logistical concerns regarding appointments.

Referring to an occupational therapist is incorrect. Occupational therapists help clients regain skills for daily living, including adaptive techniques for driving, but they do not arrange transportation.

Holding hands slightly higher than the elbows when using running water is incorrect. The proper technique is to hold hands lower than the elbows to allow water to flow downward, preventing recontamination of clean areas by dirty water.

Washing hands under running water for at least 10 seconds is incorrect. The recommended duration for effective handwashing is at least 20 seconds with soap and water to ensure the removal of pathogens.

Cleaning hands with alcohol-based hand gel for 16 seconds is incorrect. The recommended time for using alcohol-based hand rubs is at least 20 seconds, ensuring thorough coverage of all surfaces for effective pathogen removal.

Expressing conflict over independence and control is incorrect. This behavior is more characteristic of adolescents, who struggle with autonomy as they develop their identity. Nine-year-old children are still largely influenced by parents and rules.

Demonstrating self-centered thinking is incorrect. Egocentric thinking is typical in preschool-aged children, while school-aged children develop the ability to see other perspectives and think more logically.

Displaying emotional detachment from parents is incorrect. While school-aged children begin to form peer relationships, they typically maintain strong emotional connections with their parents rather than detaching from them.

Documenting in the nursing care plan is incorrect. The nursing care plan outlines interventions and client needs, but it is not used for documenting medication errors.

Recording in the controlled substance inventory record is incorrect. While the administration of a controlled substance must be recorded, the inventory record tracks medication usage and does not serve as documentation for errors.

Writing in the provider's progress notes is incorrect. The provider's progress notes focus on client status and treatment plans, not internal error reporting. However, the nurse should notify the provider about the error.

Turning on overhead lights briefly when checking IV lines is incorrect. Bright lights can disrupt sleep cycles, especially for clients who are light-sensitive or have fragmented sleep patterns. Instead, using a flashlight or bedside lamp is recommended to minimize disturbances.

Opening curtains between clients in semiprivate rooms is incorrect. Keeping curtains closed provides privacy and helps block light and noise, both of which can interfere with restful sleep.

Conducting change-of-shift report near the clients' rooms is incorrect. Shift reports should be conducted away from patient areas to prevent unnecessary noise and disruption during sleep hours.

Encouraging the toddler to flush the toilet while still seated is incorrect. Some children may be startled by the flushing sound, which can create fear and resistance to toilet training. It is better to allow the child to stand before flushing if they show hesitation.

Having the toddler remain on the toilet for a minimum of 20 minutes is incorrect. Extended sitting can lead to discomfort and frustration, making the experience negative. Shorter, 5- to 10-minute sessions are more effective and developmentally appropriate.

Waking the toddler every 2 hours in the night to prevent bed-wetting is incorrect. Nighttime bladder control develops gradually, and disrupting sleep can be counterproductive. Instead, using protective bedding and encouraging toileting before bedtime is recommended.