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This option is incorrect because an IOP of 28 mmHg is not an expected or normal finding. Normal intraocular pressure typically ranges from 10 to 21 mmHg. A reading above this range requires further evaluation and follow-up, especially to rule out chronic eye conditions such as glaucoma.

An acute eye injury may cause changes in intraocular pressure, but elevated IOP alone does not indicate acute trauma. Acute injuries are usually associated with pain, redness, visual changes, or a clear history of trauma, none of which are indicated in the scenario. Therefore, this interpretation is not supported by the information provided.

This option is incorrect because an IOP of 28 mmHg exceeds normal limits. Calling this value normal would delay necessary assessment and intervention and place the client at risk for optic nerve damage.

Antibiotics generally do not require discontinuation prior to surgery and are often continued or even initiated preoperatively to prevent or treat infection. Their use does not increase surgical risk in a way that would delay a procedure.

Analgesics are used to control pain and, depending on the type, may be continued or temporarily held on the day of surgery. Most routine analgesics do not pose a significant bleeding or anesthesia risk that would require stopping them several days in advance. Therefore, they would not typically cause surgery to be delayed.

Anti-hypertensive medications are usually continued up to and including the day of surgery to maintain blood pressure control and reduce cardiovascular risk. While some specific classes may be adjusted, they generally do not require stopping several days in advance and would not delay surgery.

This option is incorrect because teaching with your mouth around the incentive spirometer obscures lip movements and facial expressions, which are essential communication cues for clients who are hard of hearing. It also limits the client’s ability to visually follow verbal instructions and may compromise infection control.

Teaching without interrupting television watching is inappropriate because background noise interferes with communication, especially for individuals with hearing impairment. Reducing environmental distractions is a key nursing strategy to improve understanding and learning.

Shouting is ineffective and inappropriate because raising the volume can distort speech sounds, making them harder to understand. Shouting may also appear aggressive or patronizing and does not improve comprehension for clients with hearing loss.

This response is incorrect because it minimizes and normalizes Amanda’s pain in a dismissive way. While chronic pain can be common, telling a client that pain is “a normal part of living” invalidates her experience, discourages further sharing, and does not address her emotional distress or concerns about family roles. This type of response can shut down communication rather than promote it.

This response is inappropriate because it is judgmental and directive, implying that Amanda is not trying hard enough. Such statements can increase feelings of guilt, inadequacy, and withdrawal, especially in clients already struggling with chronic illness and family responsibilities. It does not encourage emotional expression or validate her concerns.

While mental health support may be beneficial in the future, immediately referring to a psychiatrist shuts down the nurse–client interaction and suggests that Amanda’s concerns are being dismissed or labeled as purely psychological. The priority at this point is to establish rapport, explore feelings, and assess her needs through therapeutic communication before escalating care.

This option is incorrect because a routine complication is a known, anticipated risk associated with certain diseases or treatments. Sentinel events are not routine or expected; they are severe, unexpected, and require urgent organizational review.

A near miss is an event that could have caused harm but did not, either by chance or timely intervention. While near misses are important for quality improvement, they do not meet the definition of a sentinel event because no actual serious harm occurred.

An expected outcome is a predictable and anticipated result of care or treatment. Sentinel events, by contrast, are unexpected, severe, and unacceptable outcomes that indicate a breakdown in patient safety systems.

The CDC focuses on disease surveillance, prevention, and public health guidance, including infection control recommendations. While it provides important safety guidelines, the CDC does not regulate or enforce workplace safety standards.

The NIH primarily conducts and supports biomedical and clinical research. It is not responsible for regulating or enforcing workplace safety standards.

The World Health Organization (WHO) is an international organization focused on global health promotion and disease prevention. It does not have authority to enforce workplace safety regulations within the United States.

This option is incorrect because pupils that are dilated and nonresponsive indicate abnormal neurologic or ocular function. PERRLA requires normal pupillary reactions, including responsiveness to both light and accommodation, which is absent in this finding.

This option is incorrect because although the pupils are described as equal and round, they do not react to light, which directly contradicts the “Reactive to Light” portion of PERRLA. Fixed pupils are an abnormal finding and may suggest neurologic impairment.

This option is incorrect because pupils that are unequal in size (anisocoria) do not meet the “Equal” requirement of PERRLA, even if they are round and reactive. PERRLA requires pupils to be equal, round, and responsive.

This option is incorrect because providing excessive detail can overwhelm the oncoming nurse and obscure critical information. Effective handoff communication prioritizes relevant, current, and safety-focused data, not a complete historical account of all events.

This option is incorrect because effective handoff communication must allow for two-way interaction and clarification. Leaving before questions can be asked increases the risk of miscommunication, missed information, and patient safety errors.

This option is incorrect because focusing primarily on completed tasks shifts attention away from the patient’s current status, risks, and anticipated needs. Handoff communication should emphasize clinical condition, pending issues, and priorities rather than task completion.

Purulent drainage is thick and often yellow, green, or brown in color and usually indicates infection. This does not match sanguineous drainage.

Serosanguineous drainage is pale pink and watery, indicating a mixture of serum and blood rather than pure blood.

Serous drainage is clear, thin, and watery, resembling plasma, and does not contain blood.