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Is not relevant to the client's question and does not provide any information or support.

Is not relevant to the client's question and does not provide any information or support.

Is not relevant to the client's question and does not provide any information or support.

May not be enough to help the client deal with his pain and may not address his psychological or emotional needs.

May not be effective in helping the client deal with his pain and may be distracting or irritating for him.

May not be necessary or appropriate for this client and may increase the risk of side effects or dependence. The PN should assess the client's pain level and response to the current dose before requesting a change in medication.

Is not the best response because it may sound defensive or sarcastic and may not deter the adolescent from making similar comments in the future.

Is not the best response because it may encourage or reinforce the adolescent's inappropriate or sexual comments and may imply that the PN is interested or flatered by them.

is not the best response because it may sound threatening or punitive and may not address the underlying issue of the adolescent's behavior. The PN should inform the parents only if the behavior persists or escalates.

Macular edema is a condition that causes swelling and fluid accumulation in the macula, the central part of the retina that is responsible for sharp and detailed vision. It can cause blurred or distorted vision, but it does not affect the optic nerve or the peripheral vision.

Cataract is a condition that causes clouding of the lens, which is the transparent structure that focuses light onto the retina. It can cause blurred, dim, or yellowed vision, but it does not affect the optic nerve or the intraocular pressure.

Diabetic retinopathy is a complication of diabetes that damages the blood vessels in the retina and causes bleeding, leakage, or scarring. It can cause blurred, fluctuating, or darkened vision, but it does not affect the optic nerve or the intraocular pressure

 Massaging the calf and foot is not recommended as it could potentially dislodge a blood clot if one is present, which can be dangerous.

 Checking the pedal pulse in the affected leg is important for assessing circulation but does not directly address the immediate discomfort of the cramp.

 Elevating the leg above the heart is generally used to reduce swelling and improve circulation but is not specifically effective for relieving muscle cramps.

A missing pulse is a pulse that is absent or cannot be detected, even with firm pressure. It indicates a complete blockage of blood flow, and may be caused by conditions such as arterial occlusion, embolism, or trauma.

Light pressure applied to pulse is not a documentation of the pulse quality, but a description of the technique used to palpate the pulse.

Is not indicated for this client and does not address his pain issue. Herpes zoster does not affect the respiratory system and does not cause hypoxia or dyspnea.

Is not a priority for this client and may not have an immediate effect on his pain. Antiviral medication can help reduce the duration and severity of Herpes zoster, but it does not provide analgesia.

Is not a priority for this client and may delay his pain relief. The PN should notify the nursing supervisor only if the prescribed analgesic is ineffective or causes adverse effects.

Hyperactive bowel sounds on assessment may indicate increased peristalsis or bowel obstruction, but they are not related to the client's symptoms or NG suctioning.

Hypoactive bowel sounds on assessment may indicate decreased peristalsis or ileus, which are expected after a bowel surgery and do not require immediate intervention

Regular heart rate of 100 beats per minute on telemetry may indicate tachycardia, which can have various causes, but it is not as concerning as PVCs in this context.

Instructing a UAP to stay with the client may not be effective or safe, as the UAP may not have the skills or training to handle an agitated client.

Notifying the client's healthcare provider is not a priority action, as it does not address the immediate safety of the client and others

Administering a PRN medication for agitation may be indicated, but it is not the first action. The PN should try non- pharmacological interventions first, unless there is an imminent risk of harm.

Is not a high priority task and can be done later or delegated to another staff member.

Is not a high priority task and can be done later or delegated to another staff member.

Is not a high priority task and can be done later or delegated to another staff member.

Asking another UAP to help the orientee may not be appropriate or necessary, as it may interfere with the orientation process and create confusion or conflict.

Verifying with the client that the bath was complete and thorough may not be sufficient or reliable, as the client may not be able to assess the quality of care or may not want to complain.

Inspecting the client's skin near the end of the bathing procedure may not be timely or comprehensive, as it may miss some aspects of care or some problems that occurred during the bath.

It is not directly related to cocaine or heroin use and can be treated with medication or surgery.

It is not directly related to cocaine or heroin use and can be managed with diet, exercise, or medication.

It is not directly related to cocaine or heroin use and can be controlled with medication or lifestyle changes.

Is not the most important follow-up assessment for this client and may not reflect the current status of the client's fluid balance or blood loss.

Is not the most important follow-up assessment for this client and may not be affected by the unsecured surgical dressing unless it is located on a limb or near a major artery.

Is not the most important follow-up assessment for this client and may not indicate the severity or cause of the client's pain.

Is not a major risk factor for falls and may not affect the client's mobility or balance.

Is not a major risk factor for falls unless the client is currently intoxicated or has chronic lung disease that impairs oxygenation or cognition.

Is not a major risk factor for falls unless it causes joint pain, edema, or difficulty moving.

Is not the responsibility of the PN but of the provider who will perform the examination.

Is not enough to ensure informed consent and may not involve any interaction with the client.

Is not enough to ensure informed consent and may not address any questions or concerns that the client may have.

A positive Babinski's reflex is a normal finding in newborns that indicates intact neurological function. It is elicited by stroking the sole of the foot and observing the fanning of the toes.

A negative Ortolani's sign is a normal finding in newborns that indicates no hip dislocation or dysplasia. It is elicited by abducting the hips and feeling for any clicking or clunking sensation.

A large sacral "stork bite" is a common benign birthmark that appears as a reddish patch on the lower back or nape of the neck. It usually fades within the first year of life and does not require any treatment.

•  C-reactive protein level - C-reactive protein (CRP) is a blood test marker for inflammation in the body. While it could indicate an infection, it is not specific enough to identify the type of infection or the causative organism.
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•  Serum albumin - Serum albumin levels can indicate a person’s nutritional status. Low levels can slow wound healing, but they do not directly indicate the presence of an infection.
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• Serum blood glucose (BG) level - High blood glucose levels can impair the immune response and slow wound healing, making a person more susceptible to infections. However, like CRP, it does not provide information about the specific organism causing the infection.

Is not necessary before self-administration of the nasal spray and may not affect the delivery of the medication.

Is not necessary for this medication and may not be relevant for this client unless they have diabetes or another condition that affects blood sugar.

Is not necessary before self-administration of the nasal spray and may not affect the delivery of the medication.

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Is a normal finding in the postpartum period and does not need to be reported. It is caused by hormonal changes and fluid shifts that occur after delivery.

Is a normal finding in the postpartum period and does not need to be reported. It is caused by increased blood flow and milk production in the breasts.

Is a normal finding in the postpartum period and does not need to be reported. It indicates that the uterine lining is healing and regenerating after delivery.