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A nursing colleague printing material that does not obtain identifiable information from a client's electronic medical record (EMR) for professional use: Using de-identified information for education or professional purposes aligns with privacy regulations. As long as no patient identifiers are included, this action maintains confidentiality and does not violate HIPAA.

A nursing colleague discussing a client's treatment plan with another nurse on the unit as part of the end-of-shift handoff report: Handoff communication between nurses directly involved in patient care is essential for continuity and safety. Sharing relevant clinical information in this context is appropriate and expected nursing practice.

A nursing colleague documenting vitals in the electronic medical record (EMR) of a client that the colleague is caring for: Accurate documentation in the EMR by the assigned nurse is a professional responsibility. This action supports safe, legal, and effective patient care.

Another nurse on the unit requests to take the newborn to the nursery to obtain newborn screening: A licensed nurse transporting a newborn for required screening is an expected and appropriate practice. This follows standard hospital protocol and does not indicate a security concern when proper identification procedures are followed.

An assistive personnel weighs and bathes the newborn in an empty client room: Assistive personnel may perform routine newborn care under facility policy and nursing delegation. While supervision and proper identification are required, this situation alone does not necessitate a security alert.

The caregiver and newborn have matching hospital identification bracelets: Matching identification bands indicate that correct newborn identification procedures are in place. This supports infant safety and does not represent a situation requiring security intervention.

Disulfiram: Disulfiram is used in the management of alcohol use disorder by producing unpleasant effects when alcohol is consumed. Disulfiram does not reduce nicotine cravings or withdrawal symptoms associated with smoking cessation.

Methadone: Methadone is a long-acting opioid agonist used for opioid use disorder and chronic pain management. Methadone has no role in reducing nicotine dependence or supporting smoking cessation efforts.

Naltrexone: Naltrexone is used to reduce cravings in alcohol and opioid use disorders. While it is excellent for blocking the sedative and pleasurable effects of opioids, it does not target the specific pathways associated with nicotine addiction and is not a standard treatment for smoking cessation.

“I insert needles into meridian lines of my child's body to help with pain relief.”: Inserting needles along meridian lines describes acupuncture, a traditional practice aimed at balancing energy flow. Acupuncture does not involve suction or heated containers placed on the skin.

"I rub the edge of a coin lengthwise on my child's back when he is sick.": Rubbing a coin on the back refers to coining, also known as gua sha, which is used to release illness or bad energy. Coining produces linear marks rather than circular suction marks.

"I apply petroleum jelly with garlic along my child's wrist to treat infectious disease.": Applying garlic with petroleum jelly reflects a topical folk remedy. This specific practice is not formally categorized as cupping or acupuncture

"I will give this medication to my child every 2 hours if he is wheezing": Montelukast is not a rescue medication and should not be administered for acute asthma attacks. Using it every 2 hours for wheezing is inappropriate and could delay effective emergency treatment.

"It takes 2 months of scheduled use before this medication is effective.": Montelukast generally begins working within a few days to weeks, not two months. Delaying assessment of effectiveness for two months could lead to uncontrolled asthma symptoms.

"I can stop giving my child this medication if he is taking a steroid.": Montelukast can be used alongside inhaled or oral steroids to manage asthma and should not be discontinued without consulting the healthcare provider. Stopping it abruptly may reduce asthma control.

Limit the client's social interactions: Limiting social interactions can increase dependence and isolation, worsening the symptoms of dependent personality disorder. Encouraging appropriate social engagement supports skill-building and autonomy.

Maintain a verbal no harm contract with the client: No-harm contracts are typically used in clients at risk for self-harm or suicide. Dependent personality disorder does not inherently involve self-harm, so this instruction is not a priority in discharge teaching.

Assume responsibility for making the client’s decisions: Making decisions for the client reinforces dependency and undermines the development of autonomy. The goal of teaching is to promote independent decision-making and self-confidence.

Provide thin liquids to help the client swallow: Thin liquids are more difficult to control and increase the risk of aspiration in clients with dysphagia. Thickened liquids are usually recommended to reduce choking and aspiration risk.

Give the client a straw to use for drinking: Using a straw can increase the risk of aspiration because it may cause the client to swallow too quickly or with less control. Direct cup drinking or other recommended methods are safer for clients with dysphagia.

Use a needleless syringe to instill feedings: A needleless syringe is not typically used for oral feedings and could increase the risk of choking or aspiration. Oral feeding should follow recommended techniques such as spoon feeding or specialized cups if indicated.

Gown: Gowns are typically used to protect against contact with infectious body fluids or contaminated surfaces. Tuberculosis is primarily transmitted via airborne droplets, so gowns are not required for routine care of a client with suspected TB.

Gloves: Gloves protect against direct contact with infectious materials or bodily fluids. While gloves may be used during procedures involving secretions, they are not the primary protective equipment for preventing inhalation of airborne TB particles.

Dosimeter badge: Dosimeter badges monitor exposure to ionizing radiation and are irrelevant in the context of airborne infectious diseases like tuberculosis. Wearing a dosimeter does not protect against TB transmission.

Pain rating of 4 on a scale of 0 to 10: Mild to moderate pain is expected in the early postoperative period due to surgical trauma. While pain should be monitored, a rating of 4 is not specific for infection and can be considered within normal postoperative discomfort.

Temperature of 37.2° C (99.0°F): A slightly elevated temperature within the normal range is common after surgery due to inflammatory response. It does not necessarily indicate infection unless it continues to rise or is accompanied by other systemic signs.

Increased urinary output: Increased urine output is generally a positive sign of adequate renal perfusion and fluid balance. It is not indicative of infection and may instead reflect normal postoperative recovery or fluid administration.

A client has difficulty voiding following the removal of an indwelling catheter: Difficulty voiding can be a common, expected postoperative or post-catheterization occurrence. It requires nursing interventions but does not warrant an incident report unless it results in harm or an adverse outcome.

A client reports nausea following the administration of morphine: Nausea is a known and common side effect of opioid medications like morphine. Monitoring and providing antiemetics are appropriate, but this event is anticipated and does not require an incident report.

A client who has type 2 diabetes mellitus did not eat their breakfast: Missing a meal may affect blood glucose control but is not considered a reportable incident. Nursing actions would include monitoring glucose and providing alternatives, rather than filing an incident report.

“I’m sure that everything will be all right, regardless of your decision”: This statement minimizes the client’s feelings and does not provide factual or supportive guidance. It can come across as dismissive of the serious implications of refusing a blood transfusion.

“If I were you, I would contact your spiritual director.”: Advising the client to follow the nurse’s personal suggestion undermines the client’s autonomy. The client may choose spiritual guidance independently, but the nurse should not impose personal recommendations.

“Making this decision is wrong”: This response is judgmental and violates the principle of respecting client autonomy. It can damage the nurse-client relationship and discourage open communication about values and preferences.

"The grieving process should be complete within 1 year.": Grieving does not follow a strict timeline and can vary greatly among individuals. Setting a fixed timeframe can create unrealistic expectations and may invalidate the family’s ongoing emotional experience.

"The stages of grief occur in sequential order": Grief is not always linear, and individuals may move back and forth between stages or experience multiple stages simultaneously. Emphasizing sequential order can misrepresent the fluid nature of grieving.

"Anticipatory grieving prolongs the grief process": Anticipatory grieving allows families to emotionally prepare for a loved one’s death and can facilitate coping, rather than prolong grief. It is a healthy aspect of the grieving process, not a negative one.

Position the client supine with legs elevated: Elevating the legs while supine is more appropriate for peripheral edema, not ascites. For ascites, semi-Fowler’s or upright positioning is preferred to promote comfort and reduce pressure on the diaphragm.

Restrict the client's sodium intake to 3 g per day: Sodium restriction is typically recommended to manage fluid retention in ascites, but standard guidelines suggest limiting sodium to 2 g per day, not 3 g, to optimize effectiveness.

Keep the client's daily protein intake below 0.8 g/kg: Clients with cirrhosis and ascites often require adequate protein to prevent muscle wasting and malnutrition. Restricting protein excessively can worsen nutritional status and is generally not recommended unless the client has hepatic encephalopathy.

Apply friction to hands for 10 seconds: Effective hand hygiene requires rubbing hands together with friction for at least 20 seconds to remove pathogens. Ten seconds is insufficient to ensure proper cleaning and reduce infection risk.

Dry hands starting from forearm to fingers: Hands should be dried from fingers to forearm to prevent contamination from runoff water. Drying in the opposite direction can transfer pathogens back onto the hands.

Use hot water to wash hands: Hot water is not recommended because it can cause skin irritation and dryness. Warm or lukewarm water is effective for hand hygiene while maintaining skin integrity.

“I am so relieved the baby looks like my mother.”: Feeling relief or comfort when noticing family resemblance in the newborn is a common emotional response. It generally reflects normal adjustment and bonding with the baby and does not indicate emotional distress requiring further evaluation.

“My appetite has really increased.”: Increased appetite postpartum can be a normal physiological response, especially with breastfeeding, as the body requires additional calories. It does not usually indicate a mental health concern or a need for further evaluation.

“My labor was so long. I'm glad it's over.”: Expressing relief or fatigue after a prolonged labor is a typical postpartum response. It shows processing of the birth experience and adjustment to recovery and newborn care, which does not warrant immediate concern.

Protamine sulfate: Protamine sulfate is used to reverse the effects of heparin, not warfarin. Administering it in warfarin toxicity would not effectively counteract the anticoagulant effect and could delay appropriate treatment.

Calcium gluconate: Calcium gluconate is primarily used to treat hypocalcemia or cardiac effects of hyperkalemia. It does not reverse warfarin-induced anticoagulation and would not address the underlying risk of bleeding.

Acetylcysteine: Acetylcysteine is an antidote for acetaminophen toxicity and works by replenishing glutathione. It has no effect on warfarin metabolism or clotting factor synthesis, making it inappropriate for this scenario.

Veracity: Veracity refers to the ethical principle of being truthful with clients. While honesty is important in nursing, providing a meal to the client addresses their immediate physiological need rather than demonstrating truthfulness.

Boundary crossing: Boundary crossing occurs when a nurse engages in actions that deviate from professional limits, potentially for personal or emotional reasons. In this case, providing food to meet a basic client need does not constitute a boundary violation.

Countertransference: Countertransference happens when a nurse projects personal feelings onto a client, which can interfere with care. The nurse’s action here is intentional and focused on meeting the client’s needs, not influenced by personal unresolved emotions.

Moderate lochia rubra on the pad: Moderate lochia 24 hours postpartum is considered a normal finding as the uterus continues to shed the lining. It typically appears bright red and gradually decreases over the following days, so it does not require immediate reporting.

Nipple tenderness with breastfeeding: Nipple tenderness is common in the early postpartum period due to breastfeeding, especially if the latch is not optimal. While it should be addressed to prevent complications, it is not an urgent finding requiring immediate reporting.

Hemorrhoids on the rectal area: Hemorrhoids are a frequent postpartum occurrence, often resulting from vaginal delivery or straining during labor. They are uncomfortable but not emergent, so they do not need immediate reporting.

Documenting suspicions in the client's medical record: While accurate documentation of objective findings is important, simply recording suspicions without following mandated reporting procedures does not fulfill the nurse’s legal responsibility. Documentation supports care but is not the primary legal action.

Notifying the caregiver of the findings: Informing the caregiver may be inappropriate and could place the client at further risk, especially if the caregiver is the suspected abuser. Legal obligations prioritize protecting the client over notifying the caregiver.

Including findings during hand-off report: Communicating relevant findings during hand-off is part of good nursing practice, but it does not meet the legal requirement to report suspected abuse to appropriate authorities.

Tongue depressor: Tongue depressors are not recommended for seizure precautions because attempting to hold the tongue during a seizure can cause oral injury or airway obstruction. They do not provide a safe or effective intervention.

Tracheostomy tray: A tracheostomy tray is used for clients with a tracheostomy, not for standard seizure precautions. Having one in the room unnecessarily does not enhance seizure safety.

Wrist restraints: Restraints are not placed prophylactically for seizure precautions. Using restraints during a seizure can cause injury and is not a recommended safety measure.

“We can accept verbal consent unless the surgical procedure is an emergency”: Verbal consent is generally insufficient for surgical procedures except in true emergencies when the client is unable to consent. Surgical informed consent typically requires written documentation to meet legal and ethical standards.

“A family member must witness your signature on the informed consent form.”: A family member is not required to witness informed consent. A nurse or authorized healthcare staff may serve as a witness to the client’s signature, confirming that it was signed voluntarily.

“We require informed consent for all routine treatments.”: Routine treatments and nursing care generally fall under implied consent. Formal informed consent is required for invasive procedures, surgeries, and treatments with significant risk, not for all routine care.

The boot allows active leg movement: Active movement of the affected leg is restricted in Buck’s traction to maintain proper alignment and traction. Excessive movement can interfere with the traction force and compromise treatment effectiveness.

The weights are just touching the floor: Weights should hang freely without touching the floor. Contact with the floor reduces the effective traction force and prevents the system from functioning as intended.

The footplate rests against the foot of the bed: The footplate should not rest against the bed, as this can alter alignment and reduce traction effectiveness. Proper positioning requires clear space to allow the traction system to work correctly.

Weight loss: Weight loss is more commonly associated with dehydration or inadequate nutritional intake. In fluid overload, clients typically demonstrate weight gain due to excess fluid retention.

Decreased skin turgor: Decreased skin turgor is a sign of fluid volume deficit rather than excess. Fluid overload usually presents with edema and taut skin rather than reduced elasticity.

Decreased blood pressure: Fluid overload is more likely to cause increased or normal blood pressure due to expanded intravascular volume. Decreased blood pressure is more consistent with hypovolemia or shock states.

Difficulty swallowing: Difficulty swallowing is more commonly associated with cranial nerve involvement, neuromuscular disorders, or medication side effects rather than pain perception. It does not reliably reflect inadequate pain control following a spinal epidural. Difficulty swallowing would prompt evaluation of airway or neurologic status rather than pain relief.

Urinary retention: Urinary retention is a known effect of spinal or epidural anesthesia due to temporary blockade of sacral nerves. It reflects autonomic nervous system involvement rather than the client’s pain level. Retention can occur even when pain is adequately managed.

Constipation: Constipation is associated with opioid use, reduced mobility, or decreased gastrointestinal motility rather than uncontrolled pain. It develops over time and is not an acute indicator of ineffective pain relief. It would prompt bowel management rather than pain reassessment.

Chloasma: Chloasma refers to hyperpigmented patches on the face, often called the "mask of pregnancy." It is a skin change due to hormonal fluctuations and does not involve the coloration of the vagina or vulva.

Ballottement: Ballottement is a technique used during a prenatal exam to detect a floating fetus by tapping the cervix, resulting in a rebound sensation. It is not related to changes in vaginal or vulvar color.

Hegar's sign: Hegar's sign is the softening of the lower uterine segment, which can be palpated during early pregnancy. It is a physical finding of the uterus, not a visual change of the vaginal or vulvar tissues.

Hypertension: Hyponatremia typically does not cause high blood pressure. In fact, low sodium levels can lead to fluid shifts and hypotension in severe cases, rather than hypertension. Monitoring blood pressure is important, but hypertension is not an expected finding of hyponatremia.

Blurred vision: Blurred vision is not a classic symptom of hyponatremia. While severe electrolyte imbalances can affect neurological function, visual changes are more commonly associated with hypernatremia or other conditions affecting the eyes.

Constipation: Constipation is not directly linked to low sodium levels. Hyponatremia primarily affects neuromuscular and neurological function, rather than gastrointestinal motility.

"Your baby is at a higher risk because they have had four bowel movements in the first day of life.": Frequent bowel movements in a newborn typically help excrete bilirubin and reduce the risk of jaundice. Therefore, having multiple stools on the first day is actually protective rather than a risk factor.

"This is because your baby is breastfed. You should start supplementing with formula.": Breastfeeding alone is not a contraindication nor an immediate reason to supplement. Breastfeeding jaundice can occur in some infants, but formula supplementation is not automatically required and should be based on assessment by the provider.

“Your baby is at a higher risk because they were born with congenital dermal melanocytosis.”: Congenital dermal melanocytosis (Mongolian spots) is a benign skin pigmentation and does not affect bilirubin metabolism.

Leg cramps: Leg cramps are a common discomfort during pregnancy due to changes in circulation and pressure from the growing uterus. While uncomfortable, they are not considered an urgent finding that requires reporting.

Urinary frequency: Increased urinary frequency is typical in the third trimester as the enlarging uterus places pressure on the bladder. This is expected and usually does not indicate a complication unless accompanied by other symptoms such as pain or dysuria.

Gingivitis: Hormonal changes during pregnancy can lead to gum inflammation and bleeding. While oral care should be reinforced, gingivitis is a common, non-urgent finding and does not require immediate reporting to the provider.

Coffee: Coffee is a stimulant and can increase gastrointestinal motility, which may worsen diarrhea. It does not help restore the balance of gut flora disrupted by antibiotics and is not recommended.

Apple juice: Apple juice is high in sugar and can have an osmotic effect in the intestines, potentially worsening diarrhea. It does not contribute to restoring normal gut flora and is not recommended to prevent antibiotic-related diarrhea.

Ice cream: Ice cream contains lactose, which can be difficult for some clients to digest, especially when gut flora is disrupted by antibiotics. This may exacerbate diarrhea rather than reduce it, making it inappropriate.

Notify the client's provider: Notifying the provider is important if there is concern for injury, but this should follow the initial assessment to determine the client’s condition. Immediate evaluation takes priority to identify any life-threatening or urgent issues.

Complete an incident report: Completing an incident report is necessary for legal and quality improvement purposes, but it is not the first priority. The client’s safety and clinical assessment take precedence over documentation.

Document the fall in the client's medical record: Accurate documentation is essential for continuity of care and legal reasons, but it should occur after assessing the client’s condition and initiating any necessary interventions.

"Individuals who have this disorder have a flat affect.": A flat affect is more commonly associated with mood disorders or schizophrenia rather than delirium. Delirium primarily affects attention, cognition, and perception, not emotional expression.

"Individuals who have this disorder speak at a slow pace.": Speech patterns in delirium are typically rapid, pressured, or incoherent rather than uniformly slow. Cognitive disorganization is more prominent than changes in speech rate.

"This disorder is not reversible.": Delirium is often reversible if the underlying cause—such as infection, medication effects, or metabolic imbalance, is identified and treated promptly. Prognosis improves with early intervention.

Reviewing the results of the client's urinalysis with their parents, without the client's consent: Routine urinalysis results are generally considered part of standard adolescent care and may be shared with parents depending on the clinic policy and state laws, so this may not necessarily breach confidentiality.

Reviewing the results of the client's celiac screening with their parents, without the client's consent: Celiac screening is part of general health testing and usually does not fall under sensitive health information; sharing these results with parents is typically permissible in pediatric care.

Reviewing the results of the client's complete blood count (CBC) with their parents, without the client's consent: A CBC is standard lab work and does not usually involve sensitive information, so sharing results with parents is generally acceptable and not considered a breach of confidentiality.

The restraint strap is tied into a knot: Restraints should be secured using a quick-release knot or buckle to allow rapid removal in case of an emergency. Tying a standard knot can prevent timely removal and is unsafe.

The skin under the restraint is cool and has changed color: Skin that is cool, discolored, or showing signs of pressure or impaired circulation indicates compromised perfusion and is a concerning finding that requires immediate intervention, not an expected outcome.

The restraint is attached to the side rails of the bed: Restraints should never be attached to side rails because this increases the risk of injury or asphyxiation if the client attempts to move. Safe restraint attachment is to the bed frame, not movable parts.

“I will position my arms away from my body when pushing an object.”: Keeping the arms away from the body increases strain on the shoulders and back, raising the risk of musculoskeletal injury. Proper technique involves keeping objects close to the body to reduce stress on joints and muscles.

"I will position my legs close together before lifting”: Keeping legs close together decreases stability and increases the likelihood of losing balance or straining the back. A wider stance is recommended to provide a stable base of support when lifting.

“I will position objects away from my body before lifting them.”: Holding objects away from the body increases leverage on the spine and muscles, elevating the risk of strain or injury. Objects should be kept close to the body during lifting to minimize stress on the back.

“I will need to remain upright for 1 hour after taking the medication.”: Remaining upright after taking medication is typically recommended for medications that may cause esophageal irritation, such as certain tablets or NSAIDs, but pantoprazole does not require this. Upright positioning is not necessary specifically for proton pump inhibitors.

“I can take antacids at the same time as this medication.”: Antacids can be taken with pantoprazole, but it is generally recommended to separate the timing by at least 30 minutes to avoid affecting the absorption and effectiveness of the proton pump inhibitor.

“I should expect to have diarrhea while taking this medication.”: While diarrhea can be a potential side effect of pantoprazole, it is not expected for every client. Most clients tolerate the medication well without gastrointestinal upset.

Assist the client with dangling off the side of the bed: While mobilization can help prevent complications such as atelectasis or thromboembolism, it does not address the immediate concern of a possible postoperative infection indicated by the elevated temperature.

Obtain a prescription to check the client's CBC: Ordering a CBC can help identify infection or inflammation, but it is a diagnostic action that follows initial assessment. Immediate assessment of potential sources of infection takes priority.

Instruct the client to breathe deeply and cough: Deep breathing and coughing are important for preventing respiratory complications, but they do not address the urgent need to assess for infection, which is indicated by the elevated temperature.

Primary care provider: The primary care provider manages overall health and follow-up care but does not typically coordinate transportation services for clients.

Physical therapist: Physical therapists focus on improving mobility, strength, and balance, which may indirectly support functional independence, but they do not coordinate transportation.

Occupational therapist: Occupational therapists help clients maintain or regain functional skills for daily activities, including driving skills, but arranging transportation to appointments falls under social work support rather than therapy interventions.

Orange juice: Orange juice is high in potassium and can significantly increase serum potassium levels. It is commonly restricted in clients who must limit potassium intake to prevent hyperkalemia.

Sweet potato: Sweet potatoes contain a high amount of potassium, especially when baked or mashed. They are typically avoided in low-potassium diets because they can rapidly elevate potassium levels.

Canned green beans: Although canned vegetables have less potassium than fresh ones due to processing, green beans still contain more potassium than wheat bread. They are not the lowest potassium option.

Gross motor skills: Rolling from abdomen to back, playing with feet, smiling responsively, and turning toward sounds are expected developmental milestones at 6 months of age. These findings indicate appropriate gross motor, social, and sensory development.

Temperature: A temperature of 37.4° C (99.3° F) is within the normal range for an infant. This finding does not suggest infection or illness and does not require provider notification.

Feeding habits: Breastfeeding combined with small amounts of cereal and fruit three times daily is appropriate for a 6-month-old infant. There is no indication from the feeding history alone that intake is inappropriate.

Positive clonus: Clonus indicates neuromuscular irritability and is a sign of worsening preeclampsia rather than therapeutic control. The presence of clonus suggests inadequate suppression of central nervous system excitability.

Respiratory rate 10/min: A respiratory rate of 10 per minute indicates respiratory depression, which is a sign of magnesium toxicity. This finding reflects an adverse effect rather than a therapeutic response.

Urinary output 20 mL/hr: Low urine output suggests impaired renal clearance of magnesium, increasing the risk for toxicity. Adequate urine output is needed to safely eliminate magnesium, so this finding is concerning rather than therapeutic.

Justice: Justice refers to fairness and equal treatment of all clients. Although important in care delivery, it does not specifically address keeping a promise or following through on a commitment to an individual client.

Autonomy: Autonomy supports the client’s right to make informed decisions about their care. While requesting pain medication reflects autonomy, the nurse’s action of returning on time aligns more directly with honoring a commitment.

Beneficence: Beneficence involves acting in the client’s best interest by promoting comfort and well-being. Administering pain medication supports beneficence, but the defining ethical principle in this scenario is the nurse’s follow-through on a promise.

“I will decrease my fluid intake to reduce incontinence.”: Reducing fluid intake can lead to concentrated urine and bladder irritation, which may worsen urinary urgency and incontinence. Adequate hydration is encouraged rather than fluid restriction for managing cystocele symptoms.

“I will experience less urinary incontinence if I use artificial sweeteners.”: Artificial sweeteners can irritate the bladder and increase urinary frequency or urgency. Their use may exacerbate urinary incontinence rather than improve symptoms.

“I should use a perineal spray to reduce odor from urinary leakage.”: Perineal sprays may mask odor but do not address the underlying pelvic floor weakness. Some products can also irritate the perineal area, potentially worsening discomfort or skin breakdown.