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Option A is incorrect because there are no abnormal findings to report to the charge nurse, as the capillary refill time was normal.

Option B is incorrect because blanching of the nailbed is what happens when pressure is applied, not when it is released, and it is not an abnormal finding.

Option C is incorrect because repeating the process with a different nailbed is not necessary, as the capillary refill time was normal on the first nailbed.

Option B is incorrect because inserting a urinary catheter is not related to seizure precautions or aspiration prevention.

Option C is incorrect because applying soft restraints may not be necessary or appropriate for a client who requires seizure precautions, as they may interfere with the natural movements of the seizure or cause injury to the client.

Option D is incorrect because inserting a nasogastric tube is not related to seizure precautions or aspiration prevention.

Thisis incorrect because it is judgmental and may offend or discourage the caregiver.

Option B is incorrect because it is not true that playpens provide a sense of security for the child, as they may feel isolated or restricted in them.

Option C is incorrect because it is not true that playpens provide a safe environment for a toddler, as they may pose hazards such as entrapment, suffocation, or injury from falling or climbing out of them.

Option B is incorrect because asking another nurse to be present may not address the client's reluctance or anxiety about looking at her incision.

Option C is incorrect because telling the client that part of recovery is accepting her new body image may sound insensitive or judgmental, and it may not reflect the client's readiness or willingness to do so.

Option D is incorrect because telling the client that she will feel better when she sees that the incision is not as bad as she may think may minimize or invalidate the client's feelings, and it may not be true or helpful.

Administering the medication and alerting the charge nurse is not necessary in this scenario. The heart rate of 120 beats/minute is within the normal range for a 2-month-old infant, which is typically between 80 to 160 beats per minute. Therefore, there is no immediate concern that would require alerting the charge nurse.

Holding the medication and documenting the cardiac assessment would be appropriate if the heart rate were outside the normal range or if there were other signs of digoxin toxicity or adverse effects. Since the heart rate is within the normal range, this action is not warranted.

Holding the medication and rechecking the heart rate in 1 hour would be considered if the heart rate were borderline or if there were concerns about the stability of the infant's condition. Since the heart rate is stable and within the normal range, this action is unnecessary.

Option B is incorrect because the name of the funeral home to contact is not relevant or necessary for the admission assessment of a terminally ill client, as it does not affect their health status or care plan.

Option C is incorrect because the client's wishes regarding organ donation may be included in their health care proxy documentation, but they are not required or essential for the admission assessment of a terminally ill client.

Option D is incorrect because the contact information for the client's next of kin may be useful for communication and support purposes, but it is not as important as the health care proxy documentation for the admission assessment of a terminally ill client.

Urinary output is not directly related to stomatitis. Stomatitis primarily affects the oral cavity, and its impact on urinary output is minimal or nonexistent. While monitoring urinary output is important for assessing hydration status, it is not the priority in this situation.

The frequency of bowel movements is unrelated to stomatitis. Stomatitis primarily affects the mouth, and its presence does not directly influence bowel movements. Assessing bowel movements may be relevant for other concerns, but it is not specifically related to stomatitis.

Blood pressure while standing, also known as orthostatic blood pressure, is not directly relevant to stomatitis. Stomatitis primarily affects the oral cavity and does not typically have a direct impact on blood pressure. Assessing blood pressure while standing may be appropriate for other health concerns, such as orthostatic hypotension, but it is not the priority in this situation.

Option A is incorrect because explaining that the healthcare provider probably prescribed a different medication while he is hospitalized is not true or helpful, as it does not verify or resolve the issue.

Option B is incorrect because telling the client that he is probably confused since being hospitalized tends to disorient clients is rude and dismissive, as it does not acknowledge or address the client's concern.

Option D is incorrect because explaining that the pharmacy often substitutes generic equivalents for more expensive brands is not accurate or relevant, as it does not verify or resolve the issue.

Hematocrit measures the proportion of red blood cells in the blood. While abnormalities in hematocrit can indicate certain conditions, such as anemia, it is not directly associated with numbness and tingling in the extremities.

Albumin and protein levels are important for assessing nutritional status and liver function. While low levels of protein can contribute to various health issues, they are not the primary concern when a client experiences numbness and tingling in the extremities.

White blood cell count (WBC): WBC count is used to evaluate the immune system's response to infection or inflammation. While infections or inflammatory conditions can cause neurological symptoms, such as tingling, it is not the primary concern in this specific case of numbness and tingling.

Therefore, the most appropriate laboratory value to prioritize reporting in this scenario is the client's electrolyte levels, as imbalances can directly contribute to the reported symptoms and may require prompt intervention.

Option A is incorrect because the child looking at the floor when answering the nurse's questions may not be a sign of abuse, but rather a sign of shyness, embarrassment, pain, or discomfort.

Option B is incorrect because the mother describing in detail what she did for her injured child may not be a sign of abuse, but rather a sign of concern, care, or guilt.

Option C is incorrect because the abrasions on the child's arms, legs, and chest having healed may not be a sign of abuse, but rather a sign of normal wound healing or previous accidents.

Positioning the infant onto the right side does not directly address the potential airway obstruction or cyanosis. While positioning may have some benefit in certain situations, such as facilitating drainage, it is not the most appropriate immediate intervention in this case.

Administering oxygen by positive pressure may be necessary if the infant's oxygen saturation remains low after suctioning and clearing the airway. However, suctioning should be the initial intervention to address any potential airway obstruction or mucus before considering oxygen administration.

Stimulating the infant to cry is not the appropriate intervention in this case. It does not directly address the potential airway obstruction or cyanosis. Crying requires a patent airway, and if the infant is already cyanotic, it suggests an obstruction or inadequate ventilation. Therefore, suctioning and clearing the airway takes precedence over stimulating the infant to cry.

In summary, when a full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic, the practical nurse should immediately suction the oral and nasal passages to clear any potential airway obstruction or mucus. This intervention aims to restore normal airflow and ensure adequate ventilation for the infant.

Consensual pupillary constriction refers to the simultaneous constriction of both pupils when light is shone into one eye. This finding is not directly related to accommodation or the client's change in focus.Therefore, it is not the appropriate documentation for the given scenario.

Nystagmus refers to involuntary eye movements that can affect the alignment and focus of the eyes. The presence of nystagmus is not mentioned in the scenario, and it is not directly related to the client's change in focus. Therefore, it is not the appropriate documentation for the given scenario.

Peripheral vision refers to the ability to see objects outside the central visual field. While important for assessing visual function, it is not directly relevant to the observed pupillary response during accommodation.

Therefore, it is not the appropriate documentation for the given scenario.
In summary, when a client's pupils constrict as they change focus from a far object to a near object, the practical nurse should document "Pupils reactive to accommodation" to accurately describe the observed pupillary response during the accommodation process.

While maintaining good hygiene is important for overall skin health, washing the hair and skin alone may not be sufficient to address acne. Acne is a multifactorial condition that requires more comprehensive treatment beyond basic hygiene practices.

While diet can play a role in overall skin health, there is limited scientific evidence linking specific foods to the development or worsening of acne. Restricting specific foods may not be the most effective or necessary approach for treating acne. Additionally, dietary changes alone may not address the underlying causes of acne.

Squeezing or expressing blackheads can potentially worsen acne and lead to skin damage or infection. It is generally not recommended to attempt self-extraction of blackheads or use aggressive exfoliating scrubs without professional guidance.
In summary, when a 16-year-old client seeks advice for acne, the most appropriate recommendation for the practical nurse (PN) is to refer the client to a dermatologist for prescribed long-term therapy. Dermatologists have the expertise to evaluate the individual's specific condition and provide appropriate treatment options tailored to their needs.

Applying a cold pack to any "hot spots" on the cast may help alleviate discomfort or itching, but it is not the highest priority instruction. Preventing scratching under the cast is more important to avoid skin damage or infection.

Keeping the left leg in a dependent position (hanging down) is not the appropriate instruction for a client with a below-the-knee cast. It is generally recommended to elevate the injured limb to reduce swelling and promote proper blood flow. Elevating the leg would involve keeping it raised above the level of the heart.

While it is possible for the client to experience some increase in pain after the application of a cast, this instruction alone is not comprehensive or specific enough for proper discharge education. Providing information about pain management strategies or when to seek medical attention for excessive pain would be more appropriate.

In summary, when discharging a client with a compound fracture of the left ankle and a below-the-knee cast, the practical nurse (PN) should provide the instruction to never scratch under the cast. This helps prevent complications and maintain the integrity of the cast, promoting proper healing of the fracture.

While it is important to provide support and reassurance to the client, simply encouraging them to continue with the scheduled surgery may not adequately address their specific concerns and fears. The charge nurse and the healthcare team should be involved in providing the necessary support and information to help alleviate the client's anxiety.

Documenting the client's concerns is important for accurate record-keeping and continuity of care. However, it should not be the only action taken. Notifying the charge nurse is crucial to ensure appropriate follow-up and support for the client.

Remind the client that the consent has already been obtained.
Reminding the client that they have already signed the informed consent may not effectively address their fears and concerns. Reassurance and support should be provided, and involving the charge nurse and healthcare team is essential to address the client's emotional well-being.

In summary, when a preoperative client confides in the practical nurse (PN) about being frightened and unsure about undergoing surgery, the priority action is to notify the charge nurse of the client's concerns. This allows for appropriate interventions, support, and coordination of care to address the client's fears, ensure their emotional well-being, and provide necessary information about the surgical procedure.

This is not the correct answer because it does not address the parents' lack of information and understanding about hypospadias. While it is important to respect the parents' autonomy and decision- making, it is also the PN's responsibility to educate them about the benefits and risks of surgery, and to correct any misconceptions or myths they may have about hypospadias. The PN should not be passive or indifferent about the parents' choice, but rather help them make an informed decision based on evidence- based practice.

This is not the correct answer because it is not true. Delaying surgery for hypospadias may increase the risk of complications such as infection, scarring, fistula formation, urethral stricture, curvature of the penis, and impaired sexual function¹². The optimal timing for surgery depends on several factors, such as the severity of hypospadias, the child's age and health status, and the surgeon's preference, but it is generally recommended to perform surgery before 18 months of age¹². The PN should not give false reassurance or misinformation to the parents, but rather explain the potential consequences of postponing surgery.

This is not the correct answer because it is also not true. Hypospadias is a congenital condition that does not improve or disappear over time. Waiting for surgery may not be beneficial, but rather harmful, as it may increase the risk of complications and psychological distress for the child¹². The PN should not give false hope or unrealistic expectations to the parents, but rather inform them about the nature and treatment of hypospadias.

This is not the correct answer because serum calcium is not directly related to nephrotoxicity. Serum calcium is the amount of calcium in the blood, which is important for bone health, muscle contraction, nerve function, and blood clotting. The normal range for serum calcium is 8.5 to 10.2 mg/dL. Serum calcium may be affected by kidney disease, but it is not a reliable indicator of nephrotoxicity.

This is not the correct answer because hemoglobin and hematocrit are not directly related to nephrotoxicity. Hemoglobin is the protein in red blood cells that carries oxygen, and hematocrit is the percentage of red blood cells in the blood. The normal range for hemoglobin is 13.5 to 17.5 g/dL for men and 12 to 15.5 g/dL for women, and for hematocrit is 38.8 to 50% for men and 34.9 to 44.5% for women.

Hemoglobin and hematocrit may be affected by kidney disease, but they are not reliable indicators of nephrotoxicity.

This is not the correct answer because WBC is not directly related to nephrotoxicity. WBC is the number of white blood cells in the blood, which are part of the immune system and fight infections. The normal range for WBC is 4,500 to 10,000 cells per microliter of blood. WBC may be elevated in response to an infection or inflammation, but it is not a reliable indicator of nephrotoxicity.

Sacral edema is commonly associated with right-sided heart failure, not left-sided heart failure. While it is important to assess for edema in clients with heart failure, inspecting for sacral edema may not be the most immediate and crucial intervention in this specific case.

Measuring urinary output is a valuable assessment in many clinical situations, but it may not be the most vital intervention in the context of left-sided heart failure. Monitoring urinary output is more relevant in assessing kidney function and fluid balance rather than directly assessing the severity of left-sided heart failure.

Checking mental acuity is important in assessing the overall condition of the client, but it is not the most crucial intervention specifically related to left-sided heart failure. Mental status evaluation is more useful in identifying signs of altered mental status or potential complications, rather than directly assessing the impact of left-sided heart failure.

This is not the most important complication for the PN to anticipate because it is not directly related to burns. Elevated blood pressure, also known as hypertension, is a condition in which the force of blood against the artery walls is too high. It can be caused by various factors, such as genetics, lifestyle, medications, or underlying diseases.

The PN should monitor the blood pressure of a client with burns, as it may reflect changes in fluid status, pain level, or infection. However, elevated blood pressure is not a common or specific complication of burns.

This is not the most important complication for the PN to anticipate because it is more likely to occur in clients with full-thickness burns than partial-thickness burns. Compartment syndrome is a condition in which increased pressure within a closed space (such as a muscle or limb) compromises blood flow and tissue perfusion. It can be caused by trauma, swelling, inflammation, infection, or tight dressings.

The PN should assess for compartment syndrome in a client with burns, especially if the burn involves a circumferential area or an extremity. The PN should look for signs and symptoms of compartment syndrome, such as severe pain, pallor, paresthesia, paralysis, and pulselessness. The PN should also loosen or remove any constrictive dressings or splints and notify the health care provider immediately if compartment syndrome is suspected.

This is not the most important complication for the PN to anticipate because it is not a complication but rather an expected outcome of burns. Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. It can be caused by various stimuli, such as heat, cold, pressure, or chemicals.

The PN should expect excruciating pain in a client who experienced partial-thickness burns over 30% of the BSA 3 days ago, as this type of burn involves damage to the epidermis and dermis layers of the skin, which contain many nerve endings. The PN should assess the pain level of the client using a valid and reliable pain scale and administer analgesics as prescribed by the health care provider. The PN should also provide nonpharmacological interventions such as distraction, relaxation techniques, music therapy, or massage to help reduce pain.