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Determining the elasticity of the client’s skin turgor is not directly related to nasopharyngeal suctioning. Skin turgor assessment is typically used to evaluate hydration status and does not provide information about the respiratory status or the need for suctioning.

Auscultating the bowel sounds in all four quadrants is unrelated to nasopharyngeal suctioning. Bowel sounds assessment is important for gastrointestinal evaluation but does not help in assessing the respiratory status or the effectiveness of suctioning.

Palpating the client’s pedal pulse volume bilaterally is not relevant to nasopharyngeal suctioning. This assessment is used to evaluate peripheral circulation and does not provide information about the respiratory status or the need for suctioning.

Requesting removal initiated by the Health Information Manager is not necessary in this scenario. The focus should be on accurately documenting the missed occurrence rather than removing previously entered documentation. This approach does not address the need to document the 0900 occurrence.

Creating an electronic correction after 1400 notes are officially unlocked implies that there was an error in the original documentation. Since the issue here is not correcting an error but rather adding missed documentation, creating a correction may not be appropriate.

Entering the occurrence after the 1400 notes and identifying it as a “late entry” is an option, but it may not provide sufficient clarity regarding the timing of the documentation. Using a “late entry” label could potentially lead to confusion or misinterpretation.

Administering PRN oral pain medication without further assessment may not be appropriate, as the client’s pain needs must be fully evaluated before intervening with medication. Pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.

Reviewing the pain medications prescribed is important, particularly if the client is exhibiting signs of uncontrolled pain. However, this intervention should be secondary to further assessment of the client’s current pain status.

Administering PRN oral pain medication without further assessment may not be appropriate, as the client’s pain needs must be fully evaluated before intervening with medication. Pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.

Positioning the head with the chin tilted slightly downward is an appropriate action when feeding a client with a CVA. This position helps prevent aspiration by closing the airway and directing food away from the trachea.

Allowing 30 minutes of rest before feeding is an appropriate action. Resting before feeding can help improve digestion and reduce the risk of aspiration by ensuring the client is alert and responsive during feeding.

Placing food on the unaffected side of the mouth is an appropriate action when feeding a client with a CVA. This technique helps the client manage food more effectively and reduces the risk of aspiration.

Wearing gloves to dispose of the needle and syringe is a good practice to prevent needlestick injuries and contamination. However, it does not directly indicate an understanding of standard precautions, which emphasize hand hygiene as a primary measure.

Removing the needle before discarding used syringes is not recommended as it increases the risk of needlestick injuries. Standard precautions emphasize the safe disposal of sharps in puncture-resistant containers without manipulating the needle.

Donning a face mask before administering medication is not a standard precaution for handling syringes and needles. Standard precautions focus more on hand hygiene and the use of gloves when there is a risk of exposure to blood or body fluids.

Telling the client to dress the right arm first is practical advice but does not address the client’s frustration and emotional state. It is important to acknowledge the client’s feelings to provide empathetic care.

Offering a class on dressing tomorrow does not address the immediate frustration and emotional response of the client. The client needs support and understanding in the moment.

Mentioning a policy against staff harassment is inappropriate and does not address the client’s frustration. It may escalate the situation and damage the nurse-client relationship.

Releasing the manometer valve immediately is not appropriate as it does not allow for an accurate measurement of systolic blood pressure.

Documenting the absence of the radial pulse is not the correct action. The nurse needs to continue the procedure to obtain an accurate systolic blood pressure reading.

Recording a palpable systolic pressure of 90 mm Hg is incorrect. The nurse needs to inflate the cuff further to obtain an accurate systolic blood pressure reading

Eschar and slough are indicative of necrotic tissue and are not signs of proper healing. Eschar is a dry, dark scab or falling away of dead skin, typically caused by a burn, or by the bite of a mite or other insect. Slough is a layer or mass of dead tissue separated from surrounding living tissue, as in a wound, sore, or inflammation. Both eschar and slough need to be removed for proper wound healing to occur.

Erythema and serosanguineous exudate can be present in the early stages of wound healing, but one week post-surgery, these signs may indicate inflammation or infection rather than

proper healing. Erythema is redness of the skin caused by increased blood flow to the capillaries, often a sign of infection or irritation. Serosanguineous exudate is a thin, watery fluid that is slightly pink due to the presence of small amounts of blood, which can be normal immediately after surgery but should decrease over time.

Beefy red granulation tissue is a sign of healing in open wounds, not in surgical incisions that are closed. Granulation tissue is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process. It is typically bright red or pink and indicates that the wound is healing from the inside out. However, in a surgical incision that is healing properly, the wound edges should be well approximated, and granulation tissue should not be visible.

Giving the client a hug and saying, “It is okay to cry when you are sad,” may be comforting, but it may also be seen as intrusive and not respecting the client’s personal space. Physical touch should be used cautiously and only when the nurse is certain that it is welcome and appropriate. Additionally, this response does not encourage the client to express their feelings or provide an opportunity for the nurse to understand the underlying cause of the client’s distress.

Saying, “I am sorry to disturb you at a difficult time. This can wait until later,” acknowledges the client’s distress but does not offer immediate support or an opportunity for the client to express their feelings. It may also give the impression that the nurse is not available to provide emotional support when needed.

Saying, “This is a bad time. I can see you are upset. I can come back later,” acknowledges the client’s distress but does not offer immediate support or an opportunity for the client to express their feelings. It may also give the impression that the nurse is not available to provide emotional support when needed.