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Sore throat – A sore throat is expected following a tonsillectomy due to the surgical site trauma. It is not an immediate concern unless accompanied by other abnormal findings such as severe pain or difficulty breathing.

Blood-tinged mucus – Small amounts of blood-tinged mucus are normal after surgery. However, active bleeding would present as bright red blood rather than a small amount of tinged mucus.

Dark brown emesis – Vomiting old blood (which appears dark brown) may occur if the child swallowed some blood postoperatively. While this should be monitored, it is not as concerning as active bleeding, which presents as bright red blood.

Diphtheria, tetanus, and acellular pertussis (DTaP) – This vaccine is primarily for children younger than 7 years old. Instead, older adults should receive the Tdap or Td vaccine as a booster every 10 years.

Human papillomavirus (HPV) – The HPV vaccine is recommended primarily for adolescents and young adults up to 26 years old to prevent cervical and other cancers. It is not typically given to older adults.

Rotavirus – The rotavirus vaccine is given to infants, as this virus causes severe diarrhea in young children. It is not needed in older adults.

Healthy weight – A BMI between 18.5 and 24.9 is classified as healthy. Since the client's BMI is 17.2, they do not fall within this range.

Overweight – Overweight is defined as a BMI between 25.0 and 29.9. The client's BMI of 17.2 is far below this range.

Obesity class 1 – Obesity is categorized as a BMI of 30.0 or higher. The client’s BMI is far below this classification.

Beneficence – This principle refers to doing good for the client, such as providing effective care and promoting well-being. While the nurse is educating the client, this action is more about truthfulness than actively promoting well-being.

Fidelity – Fidelity refers to maintaining trust and keeping commitments to the client. While honesty builds trust, fidelity is more about keeping promises rather than providing truthful information.

Autonomy – Autonomy means respecting a client’s right to make decisions about their care. While education supports informed decision-making, the nurse’s focus in this scenario is on honesty rather than respecting autonomy.

Close the doors and windows on the unit – While containing the fire is important, it is not the first priority. Activating the fire alarm ensures facility-wide response and safety protocols.

Obtain and use a fire extinguisher – Fire extinguishers are used only for small, contained fires and should be handled by trained personnel after activating the alarm.

Evacuate clients from the area – While evacuation is critical, activating the fire alarm ensures a coordinated evacuation plan rather than causing panic.

Lubricate the catheter with water-soluble gel – Lubrication is necessary to facilitate smooth insertion, but before this step, the nurse must first position the client appropriately.

Attach a prefilled syringe to the indwelling catheter inflation hub – The syringe is used to inflate the balloon after catheter insertion, so this is not the first step.

Cleanse the client's meatus with antiseptic solution – Proper cleansing is crucial to prevent infection, but before doing this, the client must be positioned correctly for visualization.

"I can expect my eyelids to be bruised after this procedure." – Bruising of the eyelids is not a typical postoperative effect of cataract surgery. The procedure is minimally invasive and does not cause significant trauma to surrounding tissues.

"I will see dark spots in my vision after this procedure." – Visual disturbances such as dark spots or floaters are not expected. Some clients may experience mild blurriness, but this should improve as the eye heals.

"I will receive general anesthesia for this procedure." – Cataract surgery is typically performed under local anesthesia with sedation, not general anesthesia. The client remains awake but does not feel pain.

Have a provider who is on site sign the prescription – The prescribing provider must sign the order within a specific timeframe, but this step occurs after verifying and documenting the prescription.

Have the unit secretary enter the prescription on the provider's order form – Only licensed personnel (nurses, pharmacists, or providers) can transcribe and verify medication orders. The unit secretary cannot enter prescriptions.

Verify the accuracy of the prescription with the pharmacist – The nurse should first confirm the order with the provider, not the pharmacist. The pharmacist’s role comes after the order is documented and entered.

. Place the client on an air mattress – While air mattresses help prevent pressure ulcers, they do not directly address mobility needs in the immediate postoperative period.

Rewrap the bandage every 8 hr in a circular pattern – The bandage should be reapplied more frequently (every 4–6 hr) using a figure-eight pattern to prevent restriction of circulation.

Turn the client every 4 hr while in bed – Clients should be turned at least every 2 hr to prevent pressure ulcers and improve circulation.

Fold the stockings at the top if they are too long – Folding the stockings can create a tourniquet effect, restricting circulation and increasing the risk of complications.

Remove the stockings every 24 hr – Antiembolitic stockings should be removed at least every 8 hr to assess skin integrity and circulation, not just once per day.

Massage the legs before applying the stockings – Massaging the legs is contraindicated in clients with DVT because it can dislodge a clot, leading to a pulmonary embolism.