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Raising the foot of the bed to a 90° angle is not an appropriate intervention for a chest wound as it may impair respiratory function further.

Preparing to insert a central line is not a priority action in managing a sucking chest wound and may delay more immediate life-saving interventions.

Removing the dressing to inspect the wound can worsen the condition by allowing more air to enter, increasing the risk of a tension pneumothorax.

Waiting only 1 hour after eating may not be enough; generally, clients with GERD are advised to wait at least 2-3 hours before lying down.

Eating four small meals each day may not be sufficient; GERD patients are often advised to eat smaller, more frequent meals to reduce stomach pressure and prevent reflux.

Drinking milk may temporarily soothe the stomach but can stimulate acid production and worsen GERD symptoms over time.

Applying cool compresses every 6 hours is not typically recommended postoperatively, as frequent, direct cooling could impede blood flow to the surgical area.

Promoting bed rest for 5-7 days is not advised; early mobility is encouraged to prevent complications such as deep vein thrombosis and improve joint function.

Encouraging increased fluid intake is important for general recovery, but it does not specifically address postoperative care for a knee replacement.

Urge incontinence may occur but is not necessarily an indicator for immediate catheterization in a paraplegic patient, as they may lack bladder control.

Weight gain is unrelated to the need for catheterization and may indicate other issues like fluid retention.

Rectal distention relates to bowel function, not bladder function, and does not indicate the need for catheterization.

Wrapping in a proximal-to-distal direction can restrict blood flow and does not provide the appropriate support needed for prosthetic shaping.

The bandage should be rewrapped more frequently than once a day to maintain compression and limb shape.

Securing the bandage at the lowest joint is inadequate as it may allow loosening and improper shaping of the residual limb.

Offering the bedpan every 2 hours helps manage elimination but does not specifically reduce the risk of urinary tract infections (UTIs).

Cleansing from back to front increases the risk of contamination from the anal area and is incorrect hygiene practice.

An indwelling catheter can increase the risk of UTIs, so intermittent catheterization is generally preferred.

Obtaining a dietary history is relevant for ongoing management but is not the initial priority.

Investigating emotional concerns is important but does not take precedence over addressing potential electrolyte imbalances that can be life-threatening.

Checking perianal skin integrity is relevant for comfort but is not the priority in stabilizing the client during an acute exacerbation.

Mottled skin is more likely observed in the later, progressive stage of shock when tissue perfusion is severely compromised.

Hypokalemia is not a typical finding in the compensatory stage of shock; electrolyte imbalances are usually more evident in later stages.

A heart rate of 160/min is typically associated with more advanced shock; in the compensatory stage, the increase is usually moderate.

A protective environment is not necessary; Clostridium difficile requires contact precautions.

Alcohol-based hand sanitizers are ineffective against Clostridium difficile spores; handwashing with soap and water is essential.

Wearing a mask is not necessary as C. difficile is transmitted through spores that survive on surfaces.