Share This Link

Rinsing forearms with running water before applying soap is not a recommended step in the handwashing procedure. The primary step is to wet the hands, apply soap, and create a lather.

Holding hands above elbow level while washing and rinsing is not a standard practice for handwashing. The hands should be washed thoroughly, and the focus is on scrubbing the hands, not their positioning.

Generating a lather by rubbing hands together vigorously for 5 seconds is insufficient for effective handwashing. Proper handwashing involves rubbing hands together for at least 20 seconds to ensure thorough cleaning.

Barrier ointment is not typically used for wound irrigation. Its purpose is to protect intact skin from moisture, friction, and other irritants, rather than to clean wounds.

Chilled irrigation solution is not commonly used for wound irrigation. Room temperature or warm sterile saline is usually recommended for wound cleansing as cold solutions can cause discomfort and vasoconstriction.

Sterile cotton balls are not used for wound irrigation. They may leave fibers in the wound, potentially leading to infection. Wound irrigation is usually performed using sterile syringes, solutions, and appropriate irrigation devices.

"Client is itching from medication." This statement is not a comprehensive description of the situation and lacks specific information. It doesn't provide any context about when the itching occurred or the client's own observation.

"It appears that the client has a rash from the medication." This statement includes an assumption and subjective language ("It appears"), which can be misleading in documentation. It's essential to provide factual and objective information in medical records.

"Rash from medication noted." This choice lacks detail and doesn't capture the client's perspective or the timing of the symptom. It's important to include the client's statement and the time frame in which the symptom occurred.

"I will place my baby on her side to sleep." Placing a baby on their side to sleep is not recommended as it increases the risk of sudden infant death syndrome (SIDS). The back sleep position is the safest for infants to reduce the risk of SIDS.

"I should avoid giving my baby a pacifier." Using a pacifier during sleep actually has a protective effect against SIDS. It's recommended to offer a pacifier at naptime and bedtime after breastfeeding is well-established.

"I will cover my baby with a light blanket when she is sleeping." The use of blankets, even lightweight ones, in an infant's sleep environment is associated with an increased risk of SIDS. It's advised to keep the crib free from blankets, pillows, and other loose items.

"Heart rate 89/min." Heart rate within the range of 60-100 beats per minute is generally considered normal for adults at rest. This value doesn't specifically indicate malnourishment.

"Pink mucous membranes." Pink mucous membranes indicate adequate oxygenation and hydration but don't necessarily reflect nutritional status or malnourishment.

"Body mass index 23." A body mass index (BMI) of 23 falls within the normal range (18.5-24.9), so it doesn't necessarily indicate malnourishment. However, BMI alone may not fully capture malnourishment, as it doesn't consider other factors like muscle mass and specific nutrient deficiencies.

Fluid overload is not a potential adverse effect of a lumbar puncture. A lumbar puncture involves the removal of cerebrospinal fluid (CSF) from the spinal canal, which wouldn't lead to fluid overload. This choice is not relevant to the procedure.

Diarrhea is not a common adverse effect of a lumbar puncture. The procedure involves accessing the spinal canal and collecting CSF, which is not directly connected to the gastrointestinal system. Diarrhea is unrelated to the procedure.

Difficulty voiding is not a common adverse effect of a lumbar puncture. The procedure involves the lower back and spinal canal, and it doesn't directly affect the urinary system. This choice is unrelated to the procedure and its potential complications.

 Placing a donut-shaped cushion in the client’s chair is not recommended as it can cause pressure points and restrict blood flow, potentially leading to pressure ulcers.

 Massaging reddened areas over bony prominences is not advisable because it can cause further damage to already compromised skin and increase the risk of pressure ulcers.

 Maintaining the client in high-Fowler’s position for extended periods can increase pressure on the sacral area, leading to pressure ulcers. It is important to regularly reposition the client to alleviate pressure.

The client's self-reported incisional pain level of 7 on a scale of 0 to 10 is important information to assess postoperative recovery, but it is not the priority finding to report among the choices. Pain management is crucial, but potential complications that could be more urgent should be addressed first.

Increased nausea and chills are concerning postoperative findings, but they could be related to the body's response to surgery, anesthesia, or pain medications. While these symptoms should be monitored and managed, they are not as high-priority as potential complications involving the calf.

An oral temperature of 38.5°C (101.3°F) indicates a fever and is also a concerning finding in the postoperative period. Infection could be a possible cause, and the provider should be informed. However, compared to tenderness and warmth in the calf, which could suggest deep vein thrombosis (DVT), the fever is of slightly lower priority.

While this statement aims to reassure the client, it may come off as dismissive of the client’s unique concerns and feelings, potentially making them feel invalidated.

Although this statement highlights the facility’s reputation, it does not directly address the client’s immediate emotional needs or concerns about the surgery.

Offering a sleeping pill addresses the symptom (inability to sleep) but does not address the underlying anxiety or emotional distress the client is experiencing. Emotional support is often more effective in such situations.