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Washing the hair and skin daily with mild soap and warm water can help maintain cleanliness, but it may not be sufficient to address acne effectively.

Expressing blackheads and using an exfoliating scrub can cause further irritation and inflammation of the skin, potentially worsening the acne.

While some people may benefit from dietary changes, there is limited evidence to suggest that omitting chocolate, carbonated drinks, and fried foods will significantly improve acne for everyone.

Assuming care of the client immediately is not necessary and may undermine the UAP's confidence and competence.

Remaining in the room to supervise the UAP is not appropriate and may interfere with the client's privacy and dignity.

Determining if the UAP would like assistance is not a priority and may not address the safety issue.

This is incorrect. Informing the client that she can go to the bathroom whenever needed is not the best action the nurse should take. The client may have a decreased sensation of bladder fullness or a weak bladder tone after a vaginal birth, which can lead to urinary retention or overflow incontinence. The nurse should encourage the client to void within 4 to 6 hours after delivery and monitor the urine output and characteristics.

This is incorrect. Advising the client to remain in bed for the next few hours is not the best action the nurse should take. The client may benefit from early ambulation after a vaginal birth, as it can promote circulation, prevent thrombosis, and enhance bowel and bladder function. The nurse should assist the client to get out of bed safely and gradually, and observe for signs of orthostatic hypotension or bleeding.

This is incorrect. Evaluating the side effects of any analgesics used during labor is not the best action the nurse should take. The client may have received analgesics, such as opioids or epidural, during labor, which can cause side effects, such as nausea, vomiting, itching, or respiratory depression. The nurse should monitor the client for these effects and provide appropriate interventions, but this is not the priority action after a vaginal birth.

A multigravida whose peri-pad is 1/4 saturated with lochia rubra after one hour does not need to be reassessed by the RN, as this is a normal finding for a client two hours post-birth. Lochia rubra is the red-colored vaginal discharge that contains blood and debris from the placental site, and it usually lasts for 3 to 4 days after delivery. A peri-pad that is 1/4 saturated after one hour is within the expected range of blood loss.

A multigravida complaining of strong afterbirth pains when breastfeeding does not need to be reassessed by the RN, as this is a normal finding for a client two hours post-birth. Afterbirth pains are cramps caused by uterine contractions that help shrink the uterus and prevent bleeding. They are more common and intense in multiparous women and during breastfeeding, as oxytocin is released and stimulates the contractions.

A primigravida who passed a small clot when she sat up on the edge of the bed does not need to be reassessed by the RN, as this is a normal finding for a client two hours post-birth. Small clots may form in the uterus or vagina due to pooling of blood during rest or anesthesia, and they are usually expelled when changing position or ambulating. As long as the clot is smaller than a plum and there is no excessive bleeding or pain, it is not a cause for concern.

The absence of a humidifier does not require immediate action, as it is not a critical component of the oxygen delivery system. A humidifier can help moisten the dry oxygen and prevent mucosal irritation, but it is not essential for oxygenation

The supine position does not require immediate action, as it is not a contraindication for oxygen therapy

The snug fit of the cannula does not require immediate action, as it is not a problem for oxygen therapy. The cannula should fit snugly against the client's cheeks to prevent dislodgment or slippage, and it does not interfere with the oxygen flow or diffusion.

This is not the correct answer because it is not a priority action that the PN should do for a postoperative patient with a PCA machine. Coffee ground secretions are dark brown or black granular material that are drained from the stomach via a nasogastric tube. They indicate bleeding in the upper gastrointestinal tract, such as from an ulcer, gastritis, or esophageal varices.

Coffee ground secretions are a serious sign that require immediate atention and treatment³. However, they are not directly related to the use of a PCA machine or postoperative pain management. The PN should monitor the nasogastric tube drainage of the postoperative patient and report any coffee ground secretions to the health care provider, but this is not a priority action for a patient with a PCA machine.

This is not the correct answer because it is not a priority action that the PN should do for a postoperative patient with a PCA machine. Nasogastric tube suctioning is a procedure that involves applying negative pressure to a nasogastric tube to remove gastric contents from the stomach.

It can be used to decompress the stomach, prevent vomiting or aspiration, or treat gastrointestinal bleeding or obstruction⁴. However, it is not directly related to the use of a PCA machine or postoperative pain management. The PN should perform nasogastric tube suctioning as ordered by the health care provider and according to protocol, but this is not a priority action for a patient with a PCA machine.

This is not the correct answer because it is not an action that the PN should do for a postoperative patient with a PCA machine. Ineffective pain management report is an outcome or evaluation that indicates that the patient's pain is not adequately controlled or relieved by the current treatment plan. It may be caused by various factors, such as inadequate dosing, inappropriate medication choice, poor adherence, tolerance, or side effects.

However, it is not an action that the PN can implement or perform for a postoperative patient with a PCA machine. The PN should assess and document the patient's pain management response and report any ineffective pain management to the health care provider, but this is not an action for a patient with a PCA machine.

This statement indicates that the client is in the stage of rationalization, as he tries to justify or minimize his condition by stating a fact that does not address his feelings or needs.

This statement indicates that the client is in the stage of anger, as he shows resentment and hostility towards those who challenge his optimism or reality.

This statement indicates that the client has reached a level of acceptance of his prognosis, as he expresses a sense of peace, gratitude, and hope. He has found sources of strength and comfort from his faith and family, and he does not show signs of denial, anger, bargaining, or depression.

Gathering the procedure tray and equipment is typically the responsibility of the healthcare provider performing the thoracentesis. The practical nurse's role in this scenario would not involve assembling the necessary materials for the procedure but rather ensuring patient safety and comfort.

Cleansing the site and covering it with a sterile towel is an important step in maintaining aseptic technique during a thoracentesis. However, this task is usually performed by the healthcare provider conducting the procedure to ensure proper sterilization techniques are followed. The practical nurse's primary focus should be on patient positioning and monitoring.

Keeping the patient NPO (nothing by mouth) and encouraging them to void is not a necessary preparation for a thoracentesis. While ensuring patient comfort is important, these actions are not specifically related to the procedure itself. The practical nurse's priorities should lie in patient positioning and ongoing assessment throughout the process.

This is not the first action to take for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Inserting an indwelling catheter requires a physician's order and may cause discomfort and infection. The client may already have a catheter in place after the surgery.

This is not enough to do for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Checking fundal consistency and monitoring lochial flow are important, but they do not address the cause of bleeding or prevent further blood loss.

This is not appropriate for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Returning the client to bed and maintaining bedrest may delay ambulation and increase the risk of thromboembolism. It also does not stop the bleeding or treat the underlying cause.

This is not the first action the PN should take when noticing that the UAP consistently records subnormal temperatures when using a tympanic thermometer.

Demonstrating how to use the equipment may be helpful, but it should be done after observing how the UAP obtains temperatures and determining the cause of the discrepancy.

This is not the first action the PN should take when noticing that the UAP consistently records subnormal temperatures when using a tympanic thermometer.

Showing UAP how to chart temperatures may be necessary, but it should be done after observing how the UAP obtains temperatures and verifying the accuracy of the data.

This is not the first action the PN should take when noticing that the UAP consistently records subnormal temperatures when using a tympanic thermometer.

Returning the thermometer for recalibration may be required, but it should be done after observing how the UAP obtains temperatures and ruling out any human or environmental factors that may affect the readings.

This is not the finding that the PN should document as evidence that the amount of insulin is inadequate for the client with type 1 diabetes mellitus.

States her feet are constantly cold along with feeling numb may indicate peripheral neuropathy, which is a complication of diabetes that affects the nerves in the feet and legs. It is caused by chronic high blood sugar levels over time, not by a single dose of insulin.

This is not the finding that the PN should document as evidence that the amount of insulin is inadequate for the client with type 1 diabetes mellitus. A wound on the ankle that starts to drain and becomes painful may indicate an infection, which is a risk factor for diabetic clients due to impaired wound healing and immune function.

It is not directly related to the insulin dose, although it may affect the blood sugar levels and require more insulin.

This is not the finding that the PN should document as evidence that the amount of insulin is inadequate for the client with type 1 diabetes mellitus. Reports nausea in the morning but still able to eat breakfast may indicate morning sickness, which is a common symptom of pregnancy.

It is not related to the insulin dose, although it may affect the blood sugar levels and require more frequent monitoring and adjustment.

This is not the information that the PN should collect during the admission assessment of a terminally ill client to an acute care facility.

Name of funeral home to contact is a personal preference that may or may not be relevant for the client at this point. It is not a priority for the admission assessment, and it may be insensitive or inappropriate to ask the client about it.

This is not the information that the PN should collect during the admission assessment of a terminally ill client to an acute care facility.

Client's wishes regarding organ donation are a personal choice that may or may not be applicable for the client depending on their diagnosis, prognosis, and eligibility. It is not a priority for the admission assessment, and it may be offensive or upsetting to ask the client about it.

This is not the information that the PN should collect during the admission assessment of a terminally ill client to an acute care facility. Contact information for the client's next of kin is a general demographic data that may or may not be relevant for the client's care.

It is not a priority for the admission assessment, and it may be already available in the client's records.

This is not the action that the PN should take prior to giving digoxin to a 2-month-old infant whose heart rate is 120 beats/minute. Alerting the charge nurse is not necessary, as the heart rate is normal and does not indicate a problem with the medication or the client's condition. The PN should administer the medication as prescribed and document the heart rate and any other relevant findings.

This is not the action that the PN should take prior to giving digoxin to a 2-month-old infant whose heart rate is 120 beats/minute. Holding the medication is not appropriate, as the heart rate is normal and does not indicate a contraindication or a risk of adverse effects from the medication. The PN should administer the medication as prescribed and document the heart rate and any other relevant findings.

This is not the action that the PN should take prior to giving digoxin to a 2-month-old infant whose heart rate is 120 beats/minute. Holding the medication and rechecking the heart rate in 1 hour is not necessary, as the heart rate is normal and does not indicate a need for further evaluation or intervention.

The PN should administer the medication as prescribed and document the heart rate and any other relevant findings.

This is not the action that the PN should take if they believe that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Telling the pharmacy to send an accurate child's dosage is not appropriate, as it may cause confusion, delay, or conflict with the healthcare provider's orders.

The PN should not assume that they know the correct dosage for the child without consulting with the healthcare provider.

This is not the action that the PN should take if they believe that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Asking another nurse if adult dosages are ever given to children is not helpful, as it may not provide accurate or reliable information.

The PN should not rely on another nurse's opinion or experience without verifying it with the healthcare provider.

This is not the action that the PN should take if they believe that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Requesting verification of the prescription by the charge nurse is not necessary, as it may waste time and resources.

The PN should be able to communicate directly with the healthcare provider and clarify any doubts or concerns about the prescription.

Encouraging exercise (option b) is generally beneficial for overall health, but it does not specifically address gingivitis.

Reminding the client to ensure dairy products are fortified with vitamin D (option c) is not necessary in this context, as the focus is on preventing gingivitis rather than addressing vitamin D deficiency.

Providing writen information about the warning signs of cancer (option d) is not directly relevant to the dentist's current situation and concern about gingivitis.

This is not the action that the PN should implement for a male client who has just been told he has cancer and asks to be left alone. Consulting with the charge nurse about implementing suicide precautions is premature and unnecessary, as there is no evidence that the client is suicidal or at risk of harming himself.

The client's request to be alone is a normal and understandable reaction to a stressful and life-changing situation, not a sign of suicidal ideation or intent.

This is not the action that the PN should implement for a male client who has just been told he has cancer and asks to be left alone. Sitting quietly in the client's room until he is ready to verbalize his feelings is intrusive and disrespectful, as it goes against the client's wishes and may make him feel uncomfortable or pressured.

The PN should not impose their presence or expectations on the client, but should honor his request and give him some privacy.

This is not the action that the PN should implement for a male client who has just been told he has cancer and asks to be left alone. Notifying a member of the client's family of the need to come stay with him is inappropriate and unethical, as it violates the client's confidentiality and autonomy.

The PN should not share the client's diagnosis or condition with anyone without his consent, nor should they assume that he wants or needs his family's support at this time. The PN should respect the client's right to decide who he wants to involve in his care and when.

Raising the head of the bed 30 degrees is not necessary or appropriate after log-rolling a client to a lateral position, as it can cause shearing forces or compromise the spinal stability. The head of the bed should be kept flat or slightly elevated during log-rolling

Measuring blood pressure and pulse rate is not the immediate intervention after log-rolling a client to a lateral position, as it does not ensure the comfort or safety of the client. The PN should monitor the vital signs before and after log-rolling, but not during or immediately after.

Flexing legs and placing blanket between legs is not the immediate intervention after log-rolling a client to a lateral position, as it does not support the spine or prevent pressure ulcers or nerve damage. The PN should keep the legs straight and aligned with the body during log-rolling, and place a pillow under the lower leg after log-rolling.