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Keep head of the bed elevated at all times:This is not specific to multiple sclerosis care and is unnecessary unless respiratory compromise is present.

Face the client directly when speaking:This instruction is more relevant to clients with hearing impairment, not MS.

Offer to assist the client with a hot bath:Hot baths can worsen MS symptoms by increasing body temperature, which may exacerbate fatigue and neurological symptoms.

Finish measuring the residual and assign the UAP to provide the bolus feeding so the PN can administer an analgesic:UAPs cannot administer tube feedings unless trained and delegated appropriately, and in most settings, PEG bolus feeding is the PN’s responsibility.

Tell the UAP that the client's pain will subside when the client is not disturbed:Ignoring or delaying pain relief is inappropriate and unethical.

Ask the UAP to finish measuring the residual volume while the PN assesses the pain level of the surgical client:Measuring gastric residual requires clinical judgment and is a PN responsibility, not a UAP task.

Unit tasks for each omission of teeth brushing:This is a form of punishment and is not as effective in promoting long-term behavioral change as positive reinforcement.

Candy for each successful hygiene task, like brushing his teeth:While it is a form of positive reinforcement, candy is not ideal due to the dental health focus of the task and potential nutritional concerns.

Privilege restriction or fines for refusals to complete a hygienic task:Punitive measures are less effective and can increase resistance.

Report the incident and the UAP for further action by the nurse-manager:Reporting may be needed later, but immediate intervention is required to stop inappropriate behavior.

Tell both of them to lower their voices in consideration of other residents:This addresses the noise but not the unprofessional and potentially abusive behavior.

Tell the resident and the UAP that shouting is not permitted:This fails to remove the UAP from the situation and address potential abuse concerns.

Give a complete bed bath to further assess the client:This could cause unnecessary pain and discomfort; comfort is the priority.

Call for ambulance transportation to the hospital immediately:The client’s condition is not unstable; hospitalization may not be indicated at this stage.

Remove the fentanyl patch as directed by prescription:Removing pain control would worsen suffering unless there is a prescription change for adverse effects.

Notify the dietary department of the change:This requires licensed staff as it involves coordination of care.

Explain the precautions to the family:Teaching is a PN/RN responsibility, not a UAP task.

Update the client's plan of care:This is a nursing responsibility and outside the UAP’s scope.

Encourage the client to resume normal activities after medication administration:Activity should be limited until pain is controlled and healing is adequate.

Assess the skin daily for areas of ecchymosis or other signs of bleeding:This is not the primary concern for an opioid; bleeding risk is not significant unless the client is on anticoagulants.

Observe the client for involuntary movements of the lips and tongue:This relates to tardive dyskinesia, associated with antipsychotics, not opioids.

A frail older adult who needs help to ambulate to the dining room for a meal:This is important but not as urgent as toileting after a diuretic.

An older adult with a colostomy who needs the bag emptied:This is routine and can wait a short time.

An older adult who needs mouth care for a dry mouth:This is comfort care and can be delayed safely.

Note that the stool color will be pink tinged:Ferrous sulfate commonly causes dark green or black stools, not pink.

Drink milk with any gastrointestinal upset:Milk decreases iron absorption and should be avoided with iron supplements.

Use the medication for no more than 21 days:Iron therapy typically continues for several months until stores are replenished, not just 21 days.

Obtain verbal consent from the client's nearest relative or significant other:Consent must come directly from the patient if they are competent. Verbal consent from a relative is not valid unless the patient is unable to consent.

Cross out the error and initial the form to ensure the correct surgery:The consent form must be corrected and re-signed by the client and provider, not altered by the nurse alone.

Transport the client to the surgery suite since medications were administered:Proceeding with surgery despite a site discrepancy risks harm and violates patient safety protocols.

"Has your child had a recent fall or injury to the head?":This might be relevant for neurological injury but is unrelated to rheumatic fever etiology.

"Does anyone in the household smoke cigarettes?":Smoking is not linked to rheumatic fever development.

"Does your child use insect repellent while outdoors?":This relates to insect-borne diseases, not rheumatic fever.

Late Middle adulthood:Calcium intake is important at all ages, but prevention is most effective before peak bone mass is reached.

Late adulthood:At this stage, bone loss prevention is still important, but most peak bone mass has already been lost.

Middle adulthood:Bone mass maintenance continues, but the critical period for maximizing peak bone mass is earlier.

Incentive spirometry is uncomfortable but necessary for your postoperative care:This statement is negative and does not explain the purpose, which may discourage use.

Failure to keep your lungs working may result in pneumonia and death:While partially true, this statement is fear-based and not therapeutic.

You will use the spirometer for the first postoperative day only:Incentive spirometry is used for several days post-op until mobility and breathing patterns normalize.

Ask the caregiver about the toddler's hospital experience:While this provides background, it doesn’t directly involve the caregiver in the assessment process.

Distract the toddler through play:Helpful to reduce anxiety but does not promote family involvement.

Explain to the toddler what will happen:Toddlers have limited understanding; caregiver participation is more effective.

Constipation and dietary modification:Not the primary concern for endocarditis; activity tolerance is more important.

Oral antibiotic administration:Route of administration is less important than ensuring completion of treatment, often given IV.

Personal hygiene and oral care:Important but not the priority over conserving energy.

Review the client's vital signs for indications of infection:Interpreting vital signs requires nursing judgment; not a UAP task.

Reassure the client that phantom limb pain is genuine pain:Providing emotional reassurance is within the PN’s role, not UAP’s.

Observe and mark the amount of drainage on the dressing:Assessment and documentation are PN responsibilities.

Nausea occurs at the onset of labor:Nausea may occur but is not the primary reason for NPO status.

Emptying time of the stomach is increased in labor:True, but the main concern is aspiration risk.

Blood is shunted from the gut during labor:Not the major factor for NPO order.

Contact the healthcare provider (HCP) about client's new onset of chest pain:Requires RN assessment before contacting the HCP.

Resume administration of the anticoagulant medication therapy:Requires provider order confirmation and RN verification.

Monitor electrocardiogram (ECG) for dysrhythmias and other abnormal changes:ECG interpretation is RN responsibility.