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The flat side-lying position is appropriate for an unconscious client during oral hygiene care. This position helps to prevent aspiration by allowing any secretions or fluids to drain out of the mouth rather than down the throat, which could happen if the client were in a Fowler's position. The presence of the emesis basin near the chin also indicates that the UAP is prepared to catch any fluids, further reducing the risk of aspiration

• Urinary output is an important indicator of fluid balance and kidney function. After delivery, a woman may experience increased urinary output due to the loss of excess fluid that was retained during pregnancy and the diuretic effect of oxytocin, which is released during breastfeeding. This is a normal and expected finding in the postpartum period.
• However, increased urinary output may also be a sign of urinary retention, which is the inability to empty the bladder completely. Urinary retention can occur due to trauma to the bladder or urethra during delivery, swelling or hematoma of the perineum, epidural anesthesia, or decreased bladder sensation.Urinary retention can lead to complications such as infection, bladder distension, or postpartum hemorrhage.

Therefore, when a woman who delivered a normal newborn 24 hours ago reports that she seems to be urinating every hour or so, the practical nurse (PN) should measure the next voiding, then palpate the client's bladder. This will help to assess the amount and quality of urine and the presence or absence of bladder distension. A normal urine output is about 30 ml per hour, and a normal bladder should feel soft and empty after voiding. If the urine output is low or high, or if the bladder feels firm or full after voiding, the PN should report these findings to the primary healthcare provider for further evaluation and intervention.

c. Administer the medication and document the heart rate.

Since the infant's heart rate of 120 beats per minute falls within the normal range for a 2-month-old, there is no indication to hold the medication. Administering the digoxin as prescribed and documenting the heart rate before administration are appropriate actions. It's important to ensure accurate documentation to track the infant's response to the medication and monitor for any changes in heart rate.

An antibiotic that can cause nephrotoxicity is an antibiotic that can damage the kidneys, which are the organs that filter the blood and remove waste products and excess fluid from the body. Some examples of nephrotoxic antibiotics are aminoglycosides, vancomycin, amphotericin B, and sulfonamides.

Serum creatinine is a laboratory value that measures the amount of creatinine in the blood. Creatinine is a waste product that is produced by the breakdown of muscle tissue and is normally excreted by the kidneys. A high serum creatinine level indicates that the kidneys are not functioning properly and are unable to filter out the creatinine from the blood.

Before administering an antibiotic that can cause nephrotoxicity, it is important for the practical nurse (PN) to review the serum creatinine level of the client, as it reflects the kidney function and the risk of nephrotoxicity. A normal serum creatinine level ranges from 0.6 to 1.2 mg/dL for men and 0.5 to 1.1 mg/dL for women. If the serum creatinine level is elevated, it may indicate that the client has impaired kidney function or is developing nephrotoxicity from the antibiotic. In this case, the PN should notify the primary healthcare provider and monitor the client for signs and symptoms of nephrotoxicity, such as decreased urine output, edema, hypertension, or electrolyte imbalances.

• Anti-Glycan Neu5Gc Antibodies (AGNA) are antibodies that recognize a carbohydrate antigen called N- glycolylneuraminic acid (Neu5Gc), which is found in animal-derived foods and tissues, but not in humans. Humans can incorporate Neu5Gc from their diet into their own cells, which can trigger an immune response and the production of AGNA.
• AGNA have been associated with various inflammatory and autoimmune diseases, such as atherosclerosis, rheumatoid arthritis, Crohn's disease, and cancer¹². AGNA may also play a role in the rejection of bioprosthetic heart valves, which are made from animal tissues that contain Neu5Gc.
• A client with carcinoma in situ of the left breast is a client with a non-invasive form of breast cancer, where the abnormal cells are confined to the ducts or lobules of the breast. This type of cancer has a high chance of cure with surgery and/or radiation therapy.
• Increased levels of AGNA in a client with carcinoma in situ of the left breast may indicate that the client has an increased risk of inflammation and infection, as AGNA can activate the complement system and recruit inflammatory cells to the site of Neu5Gc expression¹². This may impair the healing process and increase the chances of complications after surgery or radiation therapy.
• Therefore, the practical nurse (PN) should anticipate that the client's plan of care will include initiation of changes in infection control measures, such as prophylactic antibiotics, wound care, sterile dressing changes, and monitoring for signs and symptoms of infection (such as fever, redness, swelling, pain, or pus). These measures will help to prevent or treat any potential infection and promote wound healing.

It shows empathy and respect for the client's feelings, while also informing the client that the PN will be available when she is ready to look or talk about the mastectomy. Option A also implies that the PN will not pressure or force the client to do something that she is not comfortable with.

A bowel patern is the frequency, consistency, and appearance of a person's bowel movements. A normal bowel patern is what's normal for each person, and it can vary depending on factors such as diet, age, physical activity, and health conditions.

A focused gastrointestinal system assessment includes collecting subjective data about the patient's history of gastrointestinal disease, signs and symptoms of gastrointestinal problems, diet and nutrition, and bowel patern. It also includes inspecting and auscultating the abdomen for any abnormalities.

When a client reports having a bowel movement three days ago, the first action that the practical nurse should implement is to determine the client's usual bowel patern.

This will help to evaluate if the client is experiencing constipation or if this is their normal frequency. It will also help to identify any changes or risk factors that may affect the client's bowel function.

• Cocaine is a powerfully addictive stimulant drug that increases the levels of dopamine in the brain, which is a chemical messenger related to movement, pleasure, and motivation.
• Cocaine's effects appear almost immediately and last for a few minutes to an hour, depending on the method of use. Some of the short-term effects of cocaine include extreme happiness and energy, mental alertness, hypersensitivity to sight, sound, and touch, and irritability.
• An elevated energy level is one of the most common and noticeable effects of cocaine use, as cocaine stimulates the central nervous system and makes the user feel more alert, active, and confident¹². This effect may also lead to increased physical activity, talkativeness, or aggression

A radial pulse is the pulse felt at the wrist, where the radial artery runs along the thumb side of the forearm. It is one of the most common sites for measuring a person's heart rate⁴.

To measure a radial pulse, the examiner should place two or three fingers over the radial artery, just below the wrist crease, and apply gentle pressure until a pulsation is felt. The examiner should not use the thumb, as it has its own pulse and may interfere with the accuracy of the measurement. The examiner should count the number of beats for 15, 30, or 60 seconds, depending on the regularity and rate of the pulse³⁵.

In the picture, the unlicensed assistive personnel (UAP) is using the thumb to measure the radial pulse, which is incorrect. The practical nurse (PN) should demonstrate the correct pulse site to the UAP and explain why using the thumb is not appropriate. This will help to ensure that the UAP obtains an accurate and reliable pulse rate for the client.

A playpen is a portable enclosure that provides a confined space for a child to play in. It can be useful for keeping a child safe and supervised when the caregiver is busy or needs a break, but it should not be used as a substitute for active play or interaction with the caregiver or others.
- A 2-year-old child is in the developmental stage of toddlerhood, which is characterized by rapid physical, cognitive, social, and emotional growth. Toddlers are curious and eager to learn about the world around them, and they need opportunities to explore, experiment, and manipulate objects and materials. They also need stimulation, guidance, and feedback from their caregivers and peers to develop their language, problem-solving, and social skills.
- Keeping a 2-year-old child in a playpen for long periods of time or to prevent them from getting dirty can have negative effects on their development and well-being. It can limit their physical activity, creativity, and independence, and it can cause boredom, frustration, or resentment . It can also interfere with their atachment and bonding with their caregiver, as well as their self-esteem and self-image.
- Therefore, the practical nurse (PN) should use the statement "Children need time to actively explore their environment" in responding to this concern about using a playpen. This statement reflects the developmental needs and rights of the child, and it encourages the caregiver to provide a more stimulating and supportive environment for the child. It also implies that getting dirty is not a problem, but rather a natural and healthy part of play and learning.

An oil retention enema is used to soften the stool and lubricate the rectum, making it easier to pass the

stool. It is usually oil-based and contains 90-120 ml of solution.

The temperature of the enema solution affects the effectiveness and comfort of the procedure. If the solution is too hot or cold, it can cause pain, cramps, or damage to the rectal tissue. If the solution is too warm, it can also stimulate peristalsis and cause the client to expel the enema before it has time to work.

The ideal temperature for an enema solution is close to the client's body temperature, which is around 98°F or 36°C. This temperature ensures that the solution is comfortable and does not cause adverse reactions .

Seizure precautions are measures taken to protect a client who is at risk of having a seizure, which is a sudden and abnormal electrical activity in the brain that can cause changes in behavior, movement, sensation, or consciousness. Seizure precautions include providing a safe environment, monitoring the client's vital signs and neurological status, administering anticonvulsant medications, and documenting the onset, duration, and characteristics of any seizure activity.

- One of the potential complications of a seizure is aspiration, which is the inhalation of foreign material into the lungs, such as saliva, vomit, or food. Aspiration can cause choking, pneumonia, or respiratory distress. To prevent or treat aspiration, the practical nurse (PN) should ensure the ready availability of equipment to perform suctioning of the trachea, which is the tube that connects the mouth and nose to the lungs. Suctioning of the trachea involves inserting a catheter through the nose or mouth into the trachea and applying negative pressure to remove any secretions or debris from the airway.

When a primigravida client confides in the practical nurse (PN) about being in an abusive relationship, the primary concern is the safety and well-being of the client and her unborn child.

Providing contact information for a women's shelter is the most appropriate response in this situation. Women's shelters provide a safe haven for individuals experiencing domestic violence and can offer immediate assistance, including shelter, counseling, legal support, and other resources.

It reflects the appropriate and standard nursing practice of documenting any assessment findings in the client's chart. Option D also implies that the PN does not need to report, observe, or repeat anything else related to the capillary refill test, as it was done correctly and yielded normal results.

Documentation of the transfusion reaction is crucial for the client's medical history and for future reference. The nurse should record the client's signs and symptoms, the actions taken, and any other relevant information related to the reaction.

Tension pneumothorax is a life-threatening condition of air accumulation in the pleural space that causes increased intrathoracic pressure and compresses the lungs, heart, and great vessels. PEEP can increase the risk of tension pneumothorax by creating excessive positive pressure in the airways and alveoli.

A client who has cellulitis and is receiving oral antibiotics every 8 hr has a mild to moderate infection that can be managed at home with proper wound care and medication adherence. The client does not require hospitalization unless there are signs of systemic infection or complications.

A client who has cellulitis and is receiving oral antibiotics every 8 hr has a mild to moderate infection that can be managed at home with proper wound care and medication adherence. The client does not require hospitalization unless there are signs of systemic infection or complications.

D is correct because the Romberg test involves checking the client's balance with their eyes open and then with their eyes closed.