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Alcohol-based hand rubs are not recommended before administering eye drops as they can cause eye irritation.

Alcohol-based hand rubs are not effective against Clostridium difficile. Soap and water should be used instead.

Artificial nails can harbor pathogens and are not recommended in healthcare settings.

Scheduled treatments and client illness do not directly indicate the client’s pain level.

Pulse and blood pressure findings can be influenced by many factors and are not the most reliable indicators of pain.

A self-report pain rating scale would not be effective for a client with expressive aphasia as they may have difficulty understanding and using the scale.

A resolving inflammatory process would typically show a decreasing WBC count.

An allergic reaction would typically show an increase in eosinophils, not neutrophils.

Neutropenia is a decrease in neutrophils, not an increase.

Administering intravenous pain medication is important, but it is not the priority. Pain management is necessary but secondary to life-threatening conditions.

Inserting an indwelling urinary catheter is done to monitor renal function and fluid balance, but it is not the priority action in this case.

Drawing blood for a complete blood cell (CBC) count is done to assess the client’s overall health status, but it is not the priority action.

Irrigating the catheter once each shift is not recommended as it can introduce bacteria into the bladder.

Cleaning the perineal area with an antiseptic solution daily can disrupt the normal flora and cause irritation, potentially leading to infection.

Replacing the catheter every 3 days is not recommended as it can increase the risk of urinary tract infection.

Stating that they will put beverages in large containers to give the appearance of drinking a lot demonstrates a lack of understanding of fluid restriction guidelines. It focuses on the appearance rather than the actual fluid intake limitation. This statement does not reflect an understanding of the need to limit fluids in acute kidney disease.

Consuming most fluids during the evening is not recommended for clients with acute kidney disease as it may lead to discomfort, nighttime urination, and fluid overload. This statement does not demonstrate an understanding of the importance of spreading fluid intake throughout the day.

Although avoiding ice cream is an appropriate action due to its contribution to fluid intake, this statement alone does not necessarily indicate a comprehensive understanding of fluid restrictions. The client must also be aware of the importance of monitoring all sources of fluid intake, including other foods and beverages.

Placing the client back in bed during a seizure could lead to injury.

Holding the client’s arms and legs from moving could cause harm to the client or nurse.

Inserting a tongue blade in the client’s mouth could cause injury to the client’s oral cavity.

Sensitivity to light is common after cataract surgery and does not need to be reported.

Itching is common after surgery due to healing and does not need to be reported.

Difficulty with vision is expected due to the eye patch, but fear of falling should be addressed through safety measures, not necessarily reported to the provider.

A WBC count of 5,000/mm³ is within the normal range (4,500 to 11,000 cells/mm³) and is not a priority.

A platelet count of 150,000/mm³ is within the normal range (150,000 to 450,000/mm³) and is not a priority.

A positive Western blot test confirms HIV infection, but it is not a priority in this case.

Positioning the head of bed at 10 degrees is not beneficial for pneumonia patients.

Coughing and deep breathing every 8 hours is not frequent enough for pneumonia patients.

Encouraging fluid intake of 1500 mL/day is not sufficient for pneumonia patients.