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Applying the largest cuff available is important for accurate measurement, but it won’t help withdifficulty auscultating sounds.

Placing the arm above the level of the heart could result in inaccurate blood pressure readings.

Deflating the cuff too quickly can result in inaccurate readings and may also cause discomfort.

Fibromyalgia is not a contraindication for combination oral contraceptives.

Fibrocystic breast disease is not a contraindication, though it may require monitoring.

Renal calculi are not a contraindication for oral contraceptive use.

Offering clear liquids should typically occur 6 hours or later postoperatively; in the first few hours, the focus is on monitoring and pain management.

Applying a warm compress is not appropriate in the early postoperative period and may risk increased bleeding.

Giving cromolyn nebulized solution is unrelated to appendectomy recovery and is not part of standard postoperative care.

Hypotension is not typically associated with acute glomerulonephritis. Instead, hypertension is more commonly seen due to fluid retention and increased vascular resistance.

Weight loss is not typically associated with acute glomerulonephritis. Weight gain is more common due to fluid retention and edema caused by impaired kidney function.

Polyuria (excessive urination) is generally not expected in acute glomerulonephritis. Instead, oliguria (decreased urine output) is more typical, as kidney function is impaired and fluid retention occurs.

This prescription is incomplete because it lacks the dosage for Cimetidine. The nurse cannot confirm the correct amount of the medication to administer without the dosage.

While the medication name, dosage (150 units/kg), and frequency (three times weekly) are included, the route is missing. Epoetin alfa can be given via different routes (subcutaneously or intravenously), so the route must be specified.

This prescription is incomplete because it lacks both the dosage form and the frequency. It states "200 mg PO," but it does not specify whether this is a one-time dose or if it is to be given daily, which makes it unclear.

Telling the client their doctor wouldn't have ordered the treatment unless it was necessary can be dismissive of the client’s concerns and feelings.

While it’s important to acknowledge that nervousness or anxiety is a normal response, this statement does not directly address the client’s concern about not proceeding with the treatment.

Telling the client that most people feel better after the procedure may sound dismissive of theclient’s hesitation and doesn’t address their concerns directly.

Tucking the chin toward the chest (not lifting the chin) may help improve swallowing by narrowing the airway, making it easier to swallow and reducing the risk of aspiration.

Talking during feeding can increase the risk of aspiration and compromise safe swallowing.

Coughing during feedings should not be discouraged, as it may indicate that the client is attempting to clear the airway and should be monitored carefully.

Medical care cannot be initiated based on the absence of legal assistance for advance directives; this is not an appropriate response.

While a social worker may assist with legal issues, this is not the immediate response to the client’sconcern.

Advance directives must be written or documented in a specific format, and verbal agreements are insufficient.

Crusting of exudate is typical during wound healing and does not require immediate reporting unless other complications arise.

Mild swelling is expected, but it should be monitored closely.

Pink-tinged coloration is a normal part of healing and does not require reporting unless the incision shows signs of infection or other complications.

Withdrawal from pain would indicate a lower Glasgow coma scale rating and a lower level of consciousness.

Opening eyes to sound also indicates a reduced level of consciousness.

An inability to obey commands would result in a lower GCS score.

Recommending clients for discharge may be premature and disrupt ongoing care, potentially worsening the situation if those clients require immediate care.

While determining the medical needs of incoming clients through the emergency department is important, the immediate priority is ensuring sufficient staffing for the current medical needs.

Acting as a liaison between the facility and the media is an important role, but it is not the nurse's primary responsibility during a mass casualty event. The nurse should focus on direct patient care.

Reporting the defect is important, but ensuring the device is removed first is critical to prevent any potential electrical hazards to the client.

Checking the inspection sticker is necessary for regular safety checks, but this action does not address the immediate risk posed by the frayed cord.

Initiating a requisition for a replacement device is necessary but should come after the immediate action of removing the defective device.

Epistaxis (nosebleeds) is not a common manifestation of hypovolemia. It is more typically associated with conditions like hypertension or nasal trauma.

Shortness of breath is more likely to occur with conditions such as pulmonary edema or respiratory disorders, not hypovolemia.

Headache can occur in hypovolemia due to reduced blood flow, but dizziness is more directly related to the body's inability to compensate for low blood volume.

Sedation is a concern, but it does not pose an immediate life-threatening risk like respiratory depression does.

Euphoria is a common effect of morphine but does not pose an immediate risk to the child's health.

Constipation is a common side effect of morphine, but it is not an immediate priority compared to respiratory depression.

The client should not be positioned in the prone position; instead, they are typically positioned upright and leaning forward to facilitate access to the pleural space.

Positioning the client on the affected side post-procedure may not be necessary unless ordered by the provider. Standard care includes positioning the client in an upright position after the procedure to promote lung expansion.

The client is generally not NPO for thoracentesis unless specified by the healthcare provider. The focus should be on ensuring comfort and informing the client about the procedure.

Preparing the client for an MRI is not the first step; assessment of neurological status is the priority.

Inserting an indwelling urinary catheter is unnecessary unless indicated after further assessment.

Administering mannitol is appropriate for increased intracranial pressure but should only be done after assessing the client's neurological condition.

Faintness upon rising is a common symptom during pregnancy, typically due to orthostatic hypotension, and does not necessarily require reporting unless it is persistent or severe.

Bleeding gums can occur due to hormonal changes and is usually not a cause for concern.

Urinary frequency is a normal finding during pregnancy and does not need to be reported unless associated with other symptoms such as pain or fever.

The statement that the name cannot be removed once listed is incorrect. Organ donor registries may allow individuals to remove their name or change their decision at any time.

The nurse is not typically required to act as a witness for consent.

The minimum age for organ donation varies by region, but it is usually not restricted to individuals over 21 years of age.

Administering an antiemetic might be appropriate later but does not address the potential cause of vomiting, which could be malfunctioning suction.

Replacing the NG tube may be necessary if the tube is not functioning correctly, but the first step is to evaluate its effectiveness.

Providing oral hygiene care is important for comfort but does not address the immediate concern of suction malfunction.

Supervising return demonstration is important but should occur after assessing the client's understanding of how to use the diaphragm.

Documenting the client's level of understanding is part of the assessment process but not the first step.

Teaching the client how to insert the diaphragm is important, but it should be done after determiningthe client’s baseline knowledge.