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The correct answer is choice D. Identify the five major drug side effects before discharge tomorrow. This is a measurable goal as it has a specific action, which is to identify five major drug side effects, and a specific time frame, which is before discharge tomorrow. The goal is also realistic and achievable within the given time frame. Option A, sitting out of bed in the chair, is not specific enough and lacks a time frame. Option B, verbalizing feelings about surgery at some point, is too vague and lacks a specific action and time frame. Option C, eating low-sodium food, is specific but lacks a time frame and may not be realistic given the client's condition.

This represents proper delegation because passing oral medications, including blood pressure medications, is within the scope of practice for a Licensed Practical Nurse (LPN).

The correct answer is choice C. Cyanosis. Cyanosis is a medical emergency and requires immediate action by the nurse. It indicates that the client is not receiving adequate oxygenation and can lead to respiratory failure if not addressed promptly. Pallor (Option A) and erythema (Option D) are concerning but are not immediate priorities compared to cyanosis. Jaundice (Option B) may indicate liver dysfunction but is not an immediate priority unless it is associated with other symptoms such as severe abdominal pain or altered mental status.

Answer and Explanation

The correct answer is choice C, Read back the order to the physician.

After obtaining the physician's order over the phone, the nurse should read back the order to the physician to confirm accuracy and prevent medication errors.

This process ensures that the order is correctly transcribed and the right medication, dose, and route are given to the patient. Calling the pharmacy to check medication availability is not the nurse's responsibility, and initiating the prescription and administering the medication is inappropriate without confirming the order with the physician. Drawing up the medication into an appropriately labeled syringe before confirming the order with the physician is also inappropriate and can lead to medication errors. Therefore, reading back the order to the physician is the most appropriate action for the nurse to take.

The correct answer is choice B, Use water and mild soap.

When teaching a patient about ostomy care, the nurse should instruct the patient to clean the area around the ostomy with water and mild soap. Using a whirlpool bath, alcohol-based sanitizer, or chlorhexidine or HCG is not recommended as they can irritate the skin and damage the stoma. Cleansing the ostomy area with water and mild soap is the best way to maintain the skin's integrity and prevent irritation and infection.

The correct answer is choice C, "Can you tell me more about why you are undecided?"

When a patient is undecided about receiving recommended chemotherapy treatment, the most therapeutic response from the nurse would be to ask the patient to tell more about why they are undecided. This approach allows the patient to express their feelings and concerns about the treatment, which may help them come to a decision. The nurse should not tell the patient what they should do or criticize them for taking time to decide. The decision to undergo chemotherapy is a significant one, and the patient needs to feel that they have support and guidance from their healthcare provider to make an informed decision.

The correct answer is choice C, Place all 4 side rails up to prevent the patient from getting out of bed and falling.

When considering alternatives to restraints for a confused and agitated patient who is at high risk for falls, placing all 4 side rails up to prevent the patient from getting out of bed and falling is not an appropriate alternative. This action can be considered as restraint use and can increase the patient's agitation and risk for injury. Instead, the nurse should provide the patient with activities to do while in bed, play music or video selections of the patient's choice, and reduce stimulation noise and light to calm the patient.

The correct answer is choice C. Instruct the patient to inhale slowly and as deeply as possible through the mouthpiece without using the nose. Preoperative teaching on how to use an incentive spirometer is important to prevent postoperative respiratory complications such as atelectasis and pneumonia. Inhaling slowly and as deeply as possible through the mouthpiece without using the nose helps to open up the alveoli, promoting oxygen exchange in the lungs. The patient should be instructed to hold their breath for 3-5 seconds before exhaling slowly through the mouthpiece. The procedure should be repeated 10 times every hour while awake.

The correct answer is choice C. Protein is most important for wound healing. After abdominal surgery, the client requires adequate protein to promote wound healing and tissue repair. Protein is essential for collagen synthesis, a protein that is responsible for the tensile strength of the wound. The recommended daily allowance for protein for an adult is 0.8 g/kg of body weight. Foods high in protein include meat, fish, poultry, dairy products, beans, and nuts.

The correct answer is choice C. "I will need palliative care to assist with treating my symptoms so that I can have quality of life across the span of my illness." Palliative care aims to improve the quality of life of patients and their families facing life-threatening illnesses. The goal of palliative care is to provide symptom management, pain relief, and support to patients and families throughout the course of their illness. Hospice care is a type of palliative care for patients with a life expectancy of six months or less, where the focus of care is comfort rather than curative treatment.