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Administering an antipyretic is not the priority action when a transfusion reaction is suspected. Fever can be a symptom of a transfusion reaction, but stopping the transfusion and assessing the patient are more urgent. Antipyretics like acetaminophen can be given to manage fever, but only after the transfusion is halted and the patient’s overall condition has been evaluated. Addressing the root cause of the reaction takes precedence to prevent further complications.

Encouraging oral fluids is not an immediate priority during a transfusion reaction. While maintaining hydration is important, the initial step must be to stop the transfusion and assess the patient’s condition. Oral fluids do not address the underlying issue of the transfusion reaction and are not effective in managing acute symptoms. Prioritizing actions that directly mitigate the reaction is essential for patient safety.

Applying supplemental oxygen may be necessary if the patient exhibits signs of respiratory distress during a transfusion reaction. However, the first action should be to stop the transfusion to prevent further exposure to the incompatible blood product. Oxygen can be administered as a supportive measure after the transfusion is halted and the patient’s respiratory status is assessed. Addressing the immediate cause of the reaction is paramount.

Sending blood for type and crossmatch is important for identifying the cause of the transfusion reaction and ensuring safe future transfusions. However, this action is not the priority during the acute phase of a reaction. Stopping the transfusion and assessing the patient’s condition must come first to stabilize the patient and prevent further complications. Laboratory testing can be performed once the patient’s immediate needs are addressed.

Advancing from clear liquids as tolerated is important for the patient’s nutritional intake and postoperative recovery. However, it is not the most urgent task upon admission from the PACU. The nurse must first address immediate needs such as infection prevention and monitoring vital signs before considering dietary advancements. This step can be implemented once the patient’s initial postoperative stability is confirmed.

Straight catheterization if unable to void is important for managing urinary retention and preventing bladder distention. However, this intervention should be based on the patient’s condition and the amount of time since the last voiding. It is not the most urgent action upon admission from the PACU unless the patient is exhibiting signs of significant discomfort or bladder distention. Monitoring the patient’s urinary output is important but should follow the administration of prophylactic antibiotics.

Completing a blood cell count (CBC) in the morning is important for assessing the patient’s overall health and detecting any potential complications such as anemia or infection. However, it is not the most urgent action upon admission from the PACU. The nurse should prioritize tasks that address immediate postoperative needs, such as administering antibiotics and monitoring vital signs, before scheduling routine blood tests.

A client with genital herpes simplex II lesions does not require a negative airflow room or airborne precautions. Herpes simplex virus (HSV) is primarily transmitted through direct contact with infected lesions or body fluids. Standard precautions, including contact precautions when dealing with lesions, are adequate to prevent the spread of HSV. Negative airflow rooms and airborne precautions are not necessary for managing this condition.

Scarlet fever, complicated with pneumonia, primarily requires standard and droplet precautions rather than airborne precautions. Scarlet fever is caused by group A Streptococcus, which is spread through respiratory droplets. While pneumonia can increase the severity of the infection, negative airflow rooms and particulate respirators are not typically required. Droplet precautions, such as wearing masks and maintaining distance, are sufficient to prevent transmission.

Scabies is a parasitic infestation that spreads through direct skin-to-skin contact or contact with contaminated items such as bedding and clothing. Negative airflow rooms and airborne precautions are not necessary for managing scabies. Standard and contact precautions, including wearing gloves and gowns and thoroughly cleaning and disinfecting contaminated items, are adequate to prevent the spread of the mites causing scabies. The use of a particulate respirator mask is not required.

Although glucose monitoring is important, it is not the priority. Insulin administration affects potassium levels more significantly in this scenario, and glucose level fluctuations are typically less life-threatening than potassium imbalances.

Monitoring intake and output is standard practice for managing clients with electrolyte imbalances. However, it does not directly address the primary concern of potassium level fluctuations caused by insulin administration.

A daily 12-lead electrocardiogram may provide useful information on the cardiac effects of electrolyte imbalances but is less immediate in detecting rapid potassium changes than frequent serum potassium measurements.

Severe motor dysfunction indicates the degree of impairment but does not determine the extent of successful habilitation. Habilitation depends on various factors, including individual capabilities, intervention quality, and environmental support.

CP is indeed one of the most common permanent physical disabilities in children, but this statement does not directly address the mother's concern about the potential progression of impaired movements.

The continued development of the brain lesion is not a characteristic of CP. The brain damage is static, meaning it does not change, although its effects may become more apparent as the child grows and develops.

Consulting with a nurse who shares the same religious beliefs may provide insight, but it may not fully address the client's unique care preferences and individual needs.

Researching the religion on social media platforms can offer information, but it is not a substitute for understanding the client's specific preferences and requirements.

Explaining that every client receives the same high level of care is important but does not address the client's specific religious concerns and preferences.

While morbidity data for breast cancer in women of all races can provide valuable information on overall trends, it does not address the specific needs and challenges faced by African-American women. Focusing on the unique risks and barriers faced by this group is essential for designing an effective health promotion program.

A listing of African-American women who live in the community is useful for outreach and engagement but does not provide the essential insight needed to design a culturally sensitive and relevant program. Participation from community leaders is more effective in understanding and addressing the community's specific needs.

Technical assistance to produce a video on breast self-examination is valuable for education but is not the most important resource for designing a comprehensive health promotion program. The program must be tailored to the community's unique needs, which requires input from community leaders.

Administering a half dose now is not recommended because it is unclear how much of the original dose was absorbed. This could result in either an insufficient dose or an overdose, leading to ineffective treatment or potential toxicity.

Giving another dose is not safe because there is a risk of overdosing the infant. Digoxin toxicity can cause serious complications, and it is crucial to avoid administering more medication until the next scheduled dose.

Mixing the next dose with food is not appropriate because it does not address the immediate concern of potential overdose. The priority is to withhold the dose and monitor the infant's condition.

The client's healthcare power of attorney is important information but not the most urgent detail to report when there is a sudden change in the client's condition. Immediate clinical changes take priority.

The fall at home as the reason for admission provides background information but does not address the urgent change in the client's mental status. The primary focus should be on the sudden increase in confusion.

Currently prescribed medications are important to consider, especially if they could contribute to the client's confusion. However, the sudden change in mental status is more critical to report first.

Lathering using a circular movement is an effective handwashing technique. This method ensures thorough coverage of all surfaces of the hands, including areas that are often missed, such as between the fingers and under the nails. The friction generated by the circular motions helps dislodge dirt, bacteria, and viruses from the skin. Proper lathering is a crucial step in reducing the microbial load on the hands and preventing the spread of infections.

Washing hands for a total of 20 seconds is in line with the recommended guidelines from health organizations like the CDC. This duration is considered sufficient to effectively remove soil, dirt, and transient microorganisms from the skin. It allows enough time for the soap to act on contaminants and for mechanical action to dislodge them. Adhering to this time frame is an essential component of effective hand hygiene practices.

Holding hands below the elbows when rinsing ensures that water flows from the wrists down to the fingertips, effectively washing away soap and contaminants. This technique prevents recontamination of the hands by keeping the direction of water flow from the cleanest to the dirtiest areas. Proper rinsing is a key aspect of hand hygiene, ensuring that all soap residues, along with any remaining microorganisms, are thoroughly removed.

Putting the client's behavior on extinction by not acknowledging it might seem effective, but it can lead to feelings of being ignored or dismissed. This approach is not therapeutic in a psychiatric setting, where clients often require validation and structured interactions. Ignoring a client's request can escalate the behavior or contribute to a sense of isolation. Therapeutic communication involves active listening and responding appropriately to all clients.

Introducing the client to the newly admitted client and asking him to join the conversation can be disruptive and inappropriate. This action may not address the urgency of the client's concern and can intrude on the privacy and focus needed for the newly admitted client. It is important to maintain a structured and private environment for admissions to ensure that the new client feels supported and understood.

Encouraging the client to go to the nurse's station and talk with another nurse may not be practical, especially if the other nurses are also occupied. This response can seem dismissive and may not adequately address the client's immediate concern. It is more effective to provide a clear time frame or alternative solution for when the client will receive attention. Proper delegation requires ensuring that the alternative option is available and can provide the necessary support.

Pedal edema is an assessment related to heart failure or peripheral vascular disease but is not specifically connected to the adverse effects of prasugrel, which is an antiplatelet medication that primarily affects blood clotting processes.

Measuring body temperature can help detect infections or fever, but it is not a primary assessment for the adverse effects of prasugrel. The medication's adverse effects are more closely related to bleeding risks.

Assessing skin turgor is generally used to evaluate hydration status, not to monitor for adverse effects of prasugrel. This assessment would not provide relevant information about bleeding risks associated with prasugrel use.

Teaching the client to wear a mask, hand wash, and maintain social distance is essential for preventing virus spread but is secondary to protecting the healthcare provider while collecting a test sample from a symptomatic client.

Informing the client to notify others about potential exposure is an important step in contact tracing, but it does not directly protect the nurse during the specimen collection procedure.

Notifying the charge nurse about the client's need for assignment to a COVID-19 designated area is important for appropriate care and isolation but does not directly address immediate protection for the nurse during the testing procedure.

Mixed berries are rich in antioxidants and nutrients, but they do not specifically provide the calcium and vitamin D necessary to support bone health in postmenopausal women, who are at increased risk for osteoporosis.

Carrots are high in beta-carotene and fiber but do not significantly contribute to calcium and vitamin D intake. While beneficial for overall health, they are not the primary focus for bone health in postmenopausal women.

Beets offer various vitamins and minerals but lack substantial amounts of calcium and vitamin D. They are not emphasized for bone health in postmenopausal women, who need to prioritize nutrients that support bone density.

Measuring and discarding residual gastric contents before feeding is generally avoided in infants because it can disrupt gastrointestinal function and increase the risk of aspiration. Instead, monitoring for signs of intolerance or high residuals through clinical observation is preferred.

Using the syringe plunger to push formula at a rate of 5 mL per minute is inappropriate because it can create excessive pressure, leading to discomfort, aspiration, or injury to the gastrointestinal tract. Gravity feeding or using an appropriate pump at a controlled rate is safer.

Microwaving refrigerated formula to room temperature is unsafe because microwaving can create hot spots in the formula, posing a burn risk to the infant. It is safer to warm the formula by placing the bottle in warm water and ensuring an even temperature.

Explaining the ELISA test for confirmation is unnecessary as the client is already confirmed HIV positive. Repeating the test may cause confusion and anxiety without offering additional benefit at this stage.

Inquiring about plans to further education may not be timely or appropriate in the context of the client's current emotional state. The priority should be addressing the client's immediate mental health needs and ensuring they have adequate support systems in place.

Exploring feelings of hope for the future is important but may not be the immediate priority. The client is currently experiencing significant emotional distress, so addressing their immediate mental health needs and ensuring support is a higher priority.