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Ensuring that the provider has signed a prescription for restraints within 48 hr is incorrect. Restraints should never be applied without a proper prescription or order from a qualified healthcare provider. The provider's order should be obtained before applying restraints, not within 48 hours afterward.

Offering the client, a nutritious snack every 4 hr is unrelated to the use of physical restraints and should not be the nurse's priority in this situation. The focus should be on ensuring the client's safety and addressing their behavior.

Monitoring the client's range of motion every 60 min is a correct action. When a client is restrained, it's essential to monitor their physical well-being regularly. Monitoring range of motion helps ensure that the restraints are not causing harm or discomfort to the client. The specific time interval for monitoring may vary by facility policy but should be frequent enough to assess the client's condition effectively.

Bradycardia is not typically associated with cigarette smoking. Smoking is more likely to have stimulant effects on the cardiovascular system, such as increasing heart rate (tachycardia), rather than causing bradycardia.

Decreased blood pressure is incorrect. Smoking can lead to an increase in blood pressure rather than a decrease. Nicotine in cigarettes is a vasoconstrictor, which means it narrows blood vessels, leading to elevated blood pressure.

Somnolence refers to drowsiness or sleepiness, which is not typically associated with cigarette smoking. In fact, nicotine is a stimulant that can increase alertness and arousal. Therefore, somnolence is not a common adverse effect of smoking and would not be included in the teaching.

"I might have occasional seizures for several days after the procedure." This statement is not accurate. ECT does induce a controlled seizure during the procedure, but clients typically do not experience seizures after the treatment. This statement does not indicate an understanding of the procedure.

"I will have a urinary catheter in place during the procedure." This statement is not accurate. A urinary catheter is not typically used during ECT. It's important for the client to have accurate information about the procedure.

"I will need to follow a full-liquid diet for 24 hours after the procedure." This statement is not accurate. Clients undergoing ECT do not usually require a full-liquid diet afterward. The dietary restrictions may vary depending on the facility's policies, but it is not typically a full-liquid diet.

Instructing the client to cough every 4 hr. is not directly addressing the underlying issue of fluid accumulation and respiratory distress associated with heart failure. Coughing alone may not be sufficient to alleviate these symptoms.

Increasing the client's intake of oral fluids is generally not recommended without considering the client's overall fluid status. In heart failure, there is often a need to restrict fluid intake to prevent fluid overload and worsening of symptoms. Increasing oral fluids should be done cautiously and under the guidance of the healthcare provider.

Encouraging the client to ambulate to loosen secretions. While ambulation can be beneficial for some clients to improve overall circulation and prevent complications, it may not be the primary intervention in this case. The client's primary issue is likely related to pulmonary congestion due to heart failure, and they may be too short of breath to ambulate effectively.

"This medication enhances regulation of your baby's temperature." Phytonadione does not have any direct impact on the regulation of a baby's temperature. Its primary purpose is to prevent bleeding issues.

"This medication enhances your baby's immune response. Phytonadione does not enhance a baby's immune response. It primarily addresses vitamin K deficiency and associated bleeding risks.

"This medication prevents your baby from developing jaundice." Phytonadione is not used to prevent jaundice. Jaundice is typically related to bilirubin levels and is managed separately from vitamin K supplementation.

Improved respiratory function is incorrect. Pancrelipase primarily helps with the digestion and absorption of fats and fat-soluble vitamins. It does not directly impact respiratory function. Respiratory improvement in cystic fibrosis typically involves treatments such as airway clearance techniques, bronchodilators, and antibiotics to manage lung infections.

Improved absorption of vitamins B and C is incorrect. While pancrelipase can help with the absorption of fat-soluble vitamins (A, D, E, and K), it does not directly affect the absorption of vitamins B and C, which are water-soluble vitamins. Cystic fibrosis primarily affects the absorption of fat-soluble vitamins due to impaired fat digestion.

Decreased sodium excretion is incorrect. Cystic fibrosis is associated with excessive loss of salt (sodium chloride) in sweat. Pancrelipase does not directly affect sodium excretion. Treatment for managing sodium loss typically involves salt supplementation and ensuring proper hydration.

Supine is incorrect. The supine position (lying flat on the back) is not the best choice because it can increase the risk of airway obstruction and discomfort, especially if there is swelling or drainage from the surgical site.

Left lateral is incorrect. The left lateral position (lying on the left side) is not typically used after a thyroidectomy because it does not provide the same advantages for airway management, swelling reduction, and comfort as the semi-Fowler's position.

Dorsal recumbent is incorrect. The dorsal recumbent position (lying on the back with knees flexed and feet flat on the bed) is also not the most appropriate choice for post-thyroidectomy care because it does not offer the same benefits as the semi-Fowler's position in terms of airway management, swelling reduction, and comfort.

Loose stools are not a typical side effect of radiation therapy for throat cancer. Gastrointestinal side effects may occur, but they are more likely to involve symptoms such as nausea, diarrhea, or difficulty swallowing.

Bladder infection is not directly related to radiation therapy for throat cancer. The side effects of radiation therapy typically pertain to the area being treated, such as the throat and surrounding tissues.

Increased appetite is also not a common side effect of radiation therapy. Many clients may experience a decreased appetite or difficulty eating due to the side effects of radiation, such as mucositis (inflammation of the mouth and throat) or dysgeusia.

Clammy skin is incorrect. DKA is more likely to cause dry or flushed skin due to dehydration and the effects of high blood sugar levels. Clammy skin is usually associated with conditions that cause excessive sweating.

Bounding pulse is incorrect. DKA can lead to tachycardia (a rapid heart rate) as the body tries to compensate for the metabolic imbalances, but a bounding pulse is not a characteristic finding of DKA.

Elevated blood pressure is incorrect. DKA is more likely to result in an initial decrease in blood pressure due to dehydration. Elevated blood pressure may be present in other conditions but is not a primary feature of DKA.

Restraining the child's upper extremities is not recommended. It's important to allow the child to move freely during the seizure to prevent injury. Attempting to restrain their movements could result in harm to the child or the person attempting to restrain them.

Turning the child onto their back is generally appropriate as long as you do it gently and without force. It helps ensure that the airway remains clear and allows any fluids to drain out of the mouth. However, you should not forcibly turn the child; instead, gently guide them if necessary.

Placing a padded tongue blade or any object in the child's mouth is strongly discouraged during a seizure. Doing so can result in injury to the child's mouth, teeth, or jaw. It is a common misconception that someone might swallow their tongue during a seizure, but this rarely happens. It's essential to keep the child's airway clear but not to insert any objects into their mouth.

Coiling the tubing on the bed above the collection bag is incorrect because it can cause urine to flow back into the bladder, increasing the risk of infection and compromising the effectiveness of the drainage system. The tubing should be kept below the level of the bladder to ensure proper drainage.

Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which could lead to a urinary tract infection (UTI).

Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe.

Documenting the event in the client's progress notes is not the immediate action to take. While it's important to document significant events, the priority is to stop the unauthorized disclosure of the client's information and address the privacy breach.

Informing the client of the APs' actions is not the initial step to take. The priority is to address the issue and stop the conversation to prevent further disclosure of confidential information. However, the client may need to be informed about the breach of privacy as part of the organization's protocol.

Submitting an incident report to the risk manager is an appropriate step to take but should not be the first action. The immediate concern is to address the situation and stop the unauthorized discussion. After that, the incident should be documented and reported according to the facility's policies and procedures.

Decreased BUN (blood urea nitrogen) level is incorrect. While furosemide can lead to decreased BUN levels, it is not the primary indicator of its effectiveness. BUN levels can be influenced by various factors, including hydration status and kidney function.

Decreased hemoglobin level is incorrect. Furosemide is not directly associated with changes in hemoglobin levels. Hemoglobin levels reflect the oxygen-carrying capacity of the blood and are typically not affected by diuretic therapy.

Increased weight of 0.91 kg (2 lb.) is incorrect. An increase in weight is not indicative of the medication's effectiveness. In fact, weight gain could be a sign of fluid retention and heart failure exacerbation, which would suggest that the medication may not be working optimally.

Documenting the administration of medications after all assigned clients have been medicated is generally a good practice but doesn't address medication safety directly.

Reading medication labels twice before administration is an important practice, but it's not specific to patient identification or allergy checking.

Using one client identifier before administering medication is important, but it's just one aspect of ensuring patient identification. Checking allergy bands provides an additional layer of safety by confirming allergies, which can be crucial in preventing adverse reactions.

Posterior fontanel closed is incorrect, it is normal for the posterior fontanel to close earlier than the anterior fontanel, usually by 2 to 3 months of age.

Plays with toes is incorrect. At 4 months of age, infants are typically developing their motor skills, and playing with their toes is a sign of normal development.

Moves objects to mouth is incorrect. At this age, infants often explore their environment by bringing objects to their mouths as part of their sensory exploration and development.

Flossing between a 12-month-old's teeth is not typically necessary, as most children do not have enough teeth for flossing at this age. Flossing becomes more important as a child's dentition develops.

Positioning the toothbrush bristles at a 90-degree angle is not appropriate for a 12-month-old child. Parents should use a gentle, circular brushing motion, as this is more effective and less likely to cause discomfort or injury to the child's gums and teeth.

Using a 5-inch strip of toothpaste on the toothbrush is excessive for a 12-month-old. The American Academy of Pediatrics recommends using only a small smear or grain-sized amount of fluoride toothpaste for children under 3 years old to minimize the risk of swallowing too much fluoride.

"I moved the television to my bedroom for background noise." Having a television in the bedroom can be disruptive to sleep because it can interfere with relaxation and contribute to increased screen time before bed.

"I go to the 24-hour gym shortly before I go to bed." Exercising shortly before bedtime can stimulate the body and make it more difficult to fall asleep. It's generally recommended to finish exercise at least a few hours before bedtime.

"I am eating dinner later in the evening." Eating a heavy meal or eating too close to bedtime can lead to discomfort and indigestion, making it harder to sleep. It's better to have dinner at least a few hours before bedtime.

A. Applying water-soluble lubricant to the site is not typically necessary for routine site care. It may be used during the initial insertion of the tube or when changing the tube, but it's not part of routine site care.

B. Taping the tube to the child's cheek is not the recommended method for securing a gastrostomy tube. Securing the tube to the cheek may cause irritation or discomfort for the child and is not a secure method to prevent dislodgment.

C. Attaching an extension tube to the site's opening prior to use may be necessary for feeding or medication administration, but it is not specific to site care. Site care primarily involves cleaning and inspecting the site and ensuring that the tube is secure.

Select the central tip of a finger is incorrect. The nurse should select a puncture site on the side of the finger, slightly off-center from the central tip, as it tends to be less painful. The side of the finger has an adequate blood supply and can provide an accurate blood sample without causing excessive discomfort.

Wearing sterile gloves is incorrect. Sterile gloves are not typically necessary for routine capillary blood glucose monitoring. However, clean hands and proper hand hygiene are essential. The nurse should perform hand hygiene before the procedure.

Milking may hemolyze specimen and introduce excess tissue fluid.

"I should do aerobic exercises once per day." While exercise is important for individuals with COPD, the frequency and intensity of exercise should be determined based on the individual's condition and healthcare provider's recommendations. One-size-fits-all recommendations may not apply to all clients.

"I will increase my fluid intake to 1,700 milliliters per day." While staying adequately hydrated is essential, the specific fluid intake should be determined based on the client's needs, medical condition, and healthcare provider's advice. The recommended daily fluid intake can vary among individuals.

"I will consume low-protein, low-calorie foods." Nutrition is an important aspect of COPD management, but the dietary recommendations should be tailored to the client's specific needs, including their nutritional status, energy expenditure, and other factors. A generalized statement about low-protein, low-calorie foods may not be appropriate for all individuals with COPD.