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This is such a short distance and the fluid wouldn't flow as desired.

Holding the container at the client's upper hip would not provide the appropriate angle for administering the enema.

This choice does not provide specific guidance on the height or angle for administering the enema, which is crucial for the procedure's effectiveness.

Elevating the bed for the comfort of the nurse does not address the safety and comfort of the client during the transfer.

While it's important to have assistance if needed, using several people to lift the client may not always be necessary or appropriate.

This positioning is not optimal, as it makes it harder for the client to pivot and sit on the wheelchair.

Using an indwelling urinary catheter should be avoided unless absolutely necessary due to the associated risks of infection and other complications. It's not the first-line intervention for managing urinary incontinence.

Reminding the client to tell the nurse when they need to urinate can be helpful, but it may not be sufficient on its own, especially for individuals with dementia who may have difficulty recognizing or communicating their needs.

Using adult diapers should be considered a last resort, as it does not address the underlying issue and may not promote the client's independence or dignity.

Inguinal canal is not the correct location for assessing the posterior tibial pulse. This area is associated with the femoral pulse.

The knee is not the correct location for assessing the posterior tibial pulse. This area is not directly related to the posterior tibial pulse.

Dorsal aspect of the foot is where the dorsalis pedis pulse is located, not the posterior tibial pulse.

Eliciting the gag reflex is associated with cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve III.

Testing visual acuity is primarily associated with cranial nerve II (optic nerve), not cranial nerve III.

Observing facial symmetry is important for assessing cranial nerve VII (facial nerve), not cranial nerve III.

Elevating the bed for the nurse's comfort is not a priority. The focus should be on ensuring the safety and comfort of the client during the transfer.

While it's important to have enough help when transferring a client, acquiring the help of several people to lift the client may not always be necessary. It depends on the client's mobility and the specific transfer technique being used.

Locking the wheels of both the bed and the wheelchair is important, but it should be done after the client is safely positioned in the wheelchair. This helps to prevent any unintended movement during the transfer.

This statement is correct. HIPAA is a federal law that establishes privacy standards for protected health information.

This statement is correct. A client's address is considered personally identifiable information under HIPAA.

The statement appears to be cut off. However, it is important to note that HIPAA does indeed establish regulations for protecting individually identifiable health information in various forms, including verbal, electronic, and written.

After removal of an indwelling urinary catheter, it is common for a client to experience urinary frequency for a few days. This is due to the bladder readjusting to its normal function.

Blood-tinged urine may occur after catheter removal, but it is not an expected outcome. It should be assessed and reported if it occurs.

Highly concentrated urine is not typically an expected outcome after catheter removal.It may indicate dehydration or another issue that should be addressed.

Irrigating the wound with an antiseptic prior to obtaining the specimen can introduce substances that may interfere with the accuracy of the culture results. Sterile saline is the preferred solution for wound irrigation.

Intact skin at the wound edges should not be included in the culture. The specimen should be obtained directly from the wound bed or drainage.

Swabbing an area of skin away from the wound to identify the usual flora is not appropriate for obtaining a wound drainage specimen. The culture should be taken directly from the wound site.

A sheepskin heel pad is primarily used for pressure ulcer prevention, not for preventing plantar flexion contractures.

A trochanter roll is used to prevent external rotation of the hips and to maintain proper alignment. It is not specifically designed to prevent plantar flexion contractures.

An abduction pillow is used to maintain hip alignment and prevent hip adduction. It is not designed to address plantar flexion contractures.

This action involves unnecessary movement of the container and is not a standard technique for administering a cleansing enema.

Holding the container level with the client's upper hip does not provide sufficient height for the gravitational force needed to administer the enema effectively.

Keeping the container at a level to maintain client comfort is not specific guidance for administering a cleansing enema. The height of the container above the anus is a critical factor in ensuring the enema flows properly.

Having one nurse lift as the client pushes with his feet may not provide enough support and could potentially lead to an unsafe transfer, especially if the client is only partially able to assist.

Lifting the client under the shoulders with the assistance of another nurse may be appropriate for a different type of transfer, such as a sit-to-stand transfer, but it may not be the most suitable method for moving the client up in bed.

Using a trapeze bar requires the client to have a certain level of strength and mobility, and may not be suitable for a client who is only partially able to assist.

The gown should be removed next. The gown protects the nurse's clothing from contamination. Untie or unfasten the gown, and then carefully remove it, taking care to avoid touching the outside of the gown.

Face shields or goggles should be removed next if used. This helps protect the eyes and face. Handle the shield or goggles by the headband or earpieces and remove them without touching the front.

Mask should be removed last. The mask helps protect the respiratory system. Untie or unhook the mask from behind the ears or head and discard it.

Standing 1.8 m (6 feet) away from the client is not sufficient for airborne precautions.Proper respiratory protection is required, such as an N95 mask.

Allowing the client to ambulate in the hall is not a specific action related to airborne precautions. If the client needs to leave their room, they should wear a mask to prevent the spread of airborne particles.

A positive-pressure airflow room is not typically required for airborne precautions.However, ensuring proper ventilation in the room is important.

Explaining the risks and benefits of the procedure is part of the informed consent process.The client needs to be informed about potential risks, benefits, and alternatives before giving consent.

Witnessing the client's signature is an important part of the informed consent process to verify that the signature is voluntary and genuine.

Explaining the procedure to the client if they do not understand is essential for ensuring that the client has sufficient information to make an informed decision. This should be done in a clear and understandable manner.

Independently disposing of the remaining medication may not be in compliance with facility policies and could potentially interfere with an investigation into how the medication was left unattended.

Returning the medication to the unit's stock for future use is not appropriate, as the vial is already open and its integrity may be compromised.

Administering the medication to other clients is absolutely not an option. This could lead to serious harm or even fatal consequences for the other clients involved.

When caring for a client with a decreased level of consciousness who is receiving continuous enteral feedings, the top priority is to ensure the client's airway and respiratory status are maintained. This is because a decreased level of consciousness can increase the risk of aspiration, which can lead to respiratory distress or compromise.

Monitoring intake and output every 8 hours is important for overall fluid balance, but it is not the top priority in this situation.

Checking residual volume every 4 to 6 hours is a part of enteral feeding care, but it is not the top priority. Monitoring respiratory status takes precedence due to the potential risk of aspiration.

A chest tube to water seal is used to remove air or fluid from the pleural space. This does not directly impact the client's potassium levels.

A tracheostomy tube attached to humidified oxygen delivers oxygen directly to the client's airway and does not have a direct effect on potassium levels.

An indwelling urinary catheter to gravity drainage does not typically cause significant potassium loss. Urinary catheters primarily collect urine, which contains waste products, rather than electrolytes like potassium.

Using a computer terminal in a non-public area is appropriate and helps maintain client confidentiality.

Logging out of the computer before leaving a terminal is a standard practice to protect client information from unauthorized access.

Preventing an unidentified healthcare worker from viewing a health record on the computer screen is a responsible action to protect client confidentiality.

Reporting the incident to the charge nurse is an important step, but it should come after the immediate action of washing the affected area.

Going to employee health services is important for further assessment and follow-up, but it should be done after washing the area of the puncture.

Completing an incident report is an essential part of documenting the needlestick injury, but it is a secondary step that should be taken after the initial action of washing the area.