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Confirming that the medication is only administered once daily is not relevant or helpful, as it does not address the error or teach the correct technique of administering medication via a feeding tube.

Determining if the medication is compatible with the solution is not necessary or appropriate, as the medication should not be mixed with the solution in the first place, but given separately through the feeding tube.

Offering to assist in calculating the rate of flow for the mixture is not relevant or helpful, as there should be no mixture of medication and solution in the feeding bag, but separate administration of each through the feeding tube.

Questioning about which rituals are most often used to reduce anxiety is not a priority and may reinforce the client's compulsive behavior.

Asking if the obsessions and compulsions interfere with sleep is not a priority and may not address the client's emotional distress.

Determining what makes the client think people are laughing is not a priority and may not be helpful for the client's perception of reality.

Administering a prescribed narcotic antagonist may not be appropriate or necessary, as the client's agitation may not be caused by analgesic accumulation, but by other factors such as hypoxia, infection, electrolyte imbalance, or sensory deprivation.

Notifying the healthcare provider and requesting a prescription for restraints may not be the best intervention, as restraints can increase the client's agitation, anxiety, or injury. Restraints should be used only as a last resort when other measures have failed or when there is an imminent risk of harm.

Instructing a UAP to keep the upper side rails up and check on the client every 15 minutes may not be sufficient or effective, as the client may still try to get out of bed or become more agitated by being left alone. The PN should involve the family or stay with the client until he or she is calm and oriented.

Obtaining a 30 mL syringe and a vial of sterile water is not the first action because it does not address the issue of the catheter size and balloon volume.

Asking the client if she has previously been catheterized is not the first action because it does not address the issue of the catheter size and balloon volume.

Positioning the client and observing the urinary meatus is not the first action because it does not address the issue of the catheter size and balloon volume.

Offering nipple feedings of 10% dextrose may be indicated in some cases of severe hypoglycemia, but it is not the first intervention. The PN should try oral feedings of breast milk or formula first, as they are more natural and less invasive.

Repeating the heel stick for glucose in one hour may be necessary to monitor the infant's glucose level, but it is not the first intervention. The PN should treat the hypoglycemia first, as it can have serious consequences if left untreated.

Assessing for signs of hypocalcemia may be important, as hypocalcemia is another possible complication in infants of mothers with gestational diabetes, but it is not the first intervention. The PN should address the hypoglycemia first, as it is more urgent and more likely to cause jiteriness.

Using a cushion when sitting is not a priority intervention for this client and may not address the BP or mental status issues.

Performing range of motion exercises is not a priority intervention for this client and may not address the BP or mental status issues.

Documenting abdominal girth is not a priority intervention for this client and may not be an accurate indicator of fluid status.

is not enough and does not address the client's needs.

is not a priority and may not be necessary if the confusion is temporary or reversible.

is not appropriate and may worsen the confusion or disrupt the sleep-wake cycle.

Instructing the mother to play with the child for stimulation and distraction may worsen the child's condition, as it can increase his respiratory demand and anxiety.

Administering a dose of acetaminophen as needed may help reduce fever or pain, but it does not address the underlying cause of croup or improve the airway patency

Encouraging the child to drink adequate amounts of fluids may help prevent dehydration and thin the secretions, but it does not relieve the inflammation or narrowing of the airway.

This comment may be perceived as coercive or dismissive of the client's feelings, as it tries to persuade the client to do something he does not want to do or enjoy.

This comment may be perceived as accusatory or interrogatory, as it questions the client's decision or motive for staying in his room.

This comment may be perceived as minimizing or invalidating the client's feelings, as it implies that the client should not be sad or that his family is doing enough for him.

The vaccine is useful even if the person has had a case of shingles before, as shingles can recur in some people. The vaccine can prevent or reduce the severity of future episodes.

The person needs to get this vaccination even if they have had chicken pox, as shingles is caused by the reactivation of the same virus that causes chicken pox (varicella-zoster virus). The vaccine can boost the immunity against the virus and prevent it from reactivating.

The vaccination does not minimize outbreaks of cold sores, as cold sores are caused by a different virus (herpes simplex virus). The vaccine has no effect on this virus or its symptoms.

The client is not at risk for pulmonary embolism, which is a blockage of a pulmonary artery by a blood clot or other material. Pulmonary embolism does not cause elevated cardiac enzymes, but it can cause chest pain, shortness of breath, and hypoxia

The client is not at risk for pulmonary embolism, which is a blockage of a pulmonary artery by a blood clot or other material. Pulmonary embolism does not cause elevated cardiac enzymes, but it can cause chest pain, shortness of breath, and hypoxia.

The lab results do not indicate risk factors for transient ischemic atack (TIA), which is a temporary interruption of blood flow to a part of the brain due to a clot or plaque. TIA does not cause elevated cardiac enzymes, but it can cause neurological symptoms such as weakness, numbness, or speech difficulties.

Is not a priority finding and may be related to other factors such as fever, anxiety, or medication side effects.

Is an expected finding in Guillain-Barre syndrome and does not need to be reported unless it progresses rapidly or affects the respiratory muscles.

Is not a priority finding and may be related to other factors such as vasodilation, inflammation, or medication side effects.

are not at high risk of scoliosis and do not need to be screened unless they have signs or symptoms of the condition.

are at lower risk of scoliosis than middle school girls because they have completed most of their growth spurt and their condition is less likely to progress.

are at lower risk of scoliosis than middle school girls because they have a slower growth rate and a later onset of puberty.

is not the best initial intervention because it may have side effects or interactions with other drugs. The PN should assess the client's need for medication and use it as a last resort.

is not the best initial intervention because it may not address the cause of the client's difficulty in sleeping. The PN should assess the client's pain level and use other methods to relieve pain before giving medication.

is not the best initial intervention because it may contain caffeine, which can stimulate the central nervous system and keep the client awake. The PN should avoid giving caffeinated beverages to the client before bedtime.

is correct and does not indicate a need for additional information. This helps to maintain proper alignment and prevent dislocation of the prosthesis.

is correct and does not indicate a need for additional information. This helps to reduce friction and shear forces on the skin and prevent pressure ulcers.

is correct and does not indicate a need for additional information. This helps to protect their own musculoskeletal health and prevent injuries.

Periodic nausea and vomiting are common side effects of chemotherapy that can be managed with antiemetics, hydration, and dietary modifications. They are not as urgent as a high BUN level.

Decreased deep tendon reflexes may indicate hypocalcemia, hypomagnesemia, or peripheral neuropathy, which can be caused by chemotherapy or other factors. They are not as urgent as a high BUN level.

A platelet count of 135,000/mm3 or 135 x 10^9/L is slightly below the normal range, but not significantly low. Chemotherapy can cause thrombocytopenia, which increases the risk of bleeding. The PN should monitor the client for signs of bleeding, but this finding is not as urgent as a high BUN level.

are not the best site for the PN to observe because they may be affected by peripheral circulation, temperature, or edema, which can alter the color of the skin.

are not the best site for the PN to observe because they may have increased pigmentation or variations in tone that can mask changes in color.

are not the best site for the PN to observe because they may be affected by nail polish, fungal infection, or trauma, which can alter the color of the nails.