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Loosen the client's bed linens:This option is not directly related to addressing acute pain from a pressure injury. While keeping the client comfortable is important, loosening bed linens may not specifically address the pain from the sacral pressure injury.

Provide bright lights in the client's room:Bright lights may not be directly relevant to managing acute pain from a pressure injury. In fact, some clients may prefer a dimly lit environment when experiencing pain. Therefore, this option is not the most appropriate for pain management in this case.

Offer to play music in the client's room:While music can be a helpful distraction and contribute to a relaxing environment, it may not directly address the pain associated with a pressure injury. Massage, as mentioned in option C, has a more direct potential benefit for pain relief in this context.

"You need to understand that you have very little time left":This response is blunt and may be emotionally distressing for the client. It is essential to communicate with sensitivity and respect the client's autonomy. This option does not explore the available treatment options, which is important in this situation.

"Enjoy the time you have and do the things you want to do":This response may come across as dismissive and does not directly address the client's expressed desire for more treatment. It is important to acknowledge the client's wishes and explore available options before discussing end-of-life activities.

"Hospice care is the best thing for you at this time":While hospice care is an important consideration for individuals with terminal illnesses, it may not align with the client's current preference for more treatment. Introducing hospice care at this point without discussing treatment options may be premature.

A feeling of swelling in the feet:Swelling in the feet is not a typical sign of an anaphylactic reaction to an IM antibiotic injection. Anaphylaxis usually involves more rapid and widespread symptoms that can affect various body systems.

Pain at the injection site:Pain at the injection site is a common side effect of intramuscular (IM) injections and is not typically indicative of an anaphylactic reaction. Anaphylactic reactions are characterized by more systemic and severe symptoms.

A sudden decrease in heart rate:An anaphylactic reaction typically involves an increase in heart rate rather than a decrease. The body's response to an allergen in an anaphylactic reaction often includes a rapid heart rate, as part of the systemic release of inflammatory mediators.

Assist the client with a bowel cleansing:This action is not directly related to an intravenous pyelogram (IVP). IVP is a radiographic examination of the kidneys, ureters, and bladder. Bowel cleansing is more commonly associated with procedures such as colonoscopy.

Monitor the client for pain in the suprapubic region:While it is important to monitor for pain or discomfort during and after the procedure, pain in the suprapubic region may not specifically indicate complications related to the IVP. Monitoring for general discomfort or any signs of an allergic reaction to contrast material is crucial.

Administer 240 mL (8 oz) of oral contrast before the procedure:This action is more relevant to procedures such as a CT scan with oral contrast, not an IVP. In an IVP, contrast material is typically injected intravenously, not taken orally.

Eyelids that blink involuntarily 30 to 35 times per minute:The normal range for involuntary blinking is approximately 15 to 20 times per minute. A rate of 30 to 35 blinks per minute may suggest increased nervousness or anxiety and is not within the expected normal range.

Corneas with an opaque appearance:Normal corneas should have a clear and transparent appearance. Opacity of the cornea can be indicative of various eye conditions, such as corneal edema or scarring, and is not an expected finding in a healthy eye.

Pupils that are 8 to 9 mm in diameter:The normal range for pupil size is approximately 2 to 6 mm in diameter. Pupils that are 8 to 9 mm in diameter may indicate abnormal dilation (mydriasis) and can be associated with conditions such as drug toxicity or neurological issues.

Massaging the client's bony prominences: Massage can increase the risk of tissue damage and is not recommended as a preventive measure for pressure injuries.

Raising the head of the client's bed to a 60° angle: While elevation may be beneficial for certain conditions, it is not a direct preventive measure for pressure injuries. Repositioning and pressure relief are more crucial.

Repositioning the client regularly is indeed a crucial measure to prevent pressure injuries. However, repositioning every 2 hours is typically recommended for clients at risk of developing pressure injuries, as prolonged pressure on any one area can lead to tissue damage.

The client tucks their chin when they swallow:This is a proper swallowing technique. Tucking the chin helps close off the airway during swallowing, reducing the risk of aspiration. It facilitates the safe passage of food or liquids into the esophagus

The client adjusts the head of their bed to 90°:This action is appropriate. Keeping the head of the bed elevated to 30 to 45 degrees is recommended for clients with dysphagia as it helps prevent aspiration during swallowing.

The client takes frequent breaks while eating:This action is also appropriate. Clients with dysphagia may need to take breaks between bites to ensure safe and effective swallowing. It allows the client to pace themselves and reduces the risk of aspiration.

Loosen the client's clothing:While ensuring a patent airway is essential, it is not the immediate priority when the client is actively seizing. The primary concern is preventing injury by helping the client lie on the floor.

Turn the client onto their side:This action is part of the process after helping the client lie on the floor. Turning the client onto their side helps prevent aspiration in case of vomiting and maintains an open airway.

Move items in the room away from the client:While creating a safe environment by moving objects away is important, the immediate priority is to prevent injury to the client. Helping the client lie on the floor takes precedence to minimize the risk of injury during the seizure.

Supine in low-Fowler's position:The supine position is less effective for draining secretions from the lower lobes. In this position, gravity is not as conducive to moving mucus out of the affected area, especially from the left lower lobe.

Right lateral in Trendelenburg position:Placing the client in a Trendelenburg position (head down, legs up) is generally not recommended for postural drainage. It can lead to increased intracranial pressure and may not effectively target the specific area of the left lower lobe.

Prone with pillows under the lower extremities:Placing the client prone with pillows under the lower extremities is not the optimal position for postural drainage of the left lower lobe. This position may be used for other areas of the lungs but is not the best choice for targeting the left lower lobe

Use a quick-release knot to secure the ties:This is not the best practice. Quick-release knots are not recommended for securing tracheostomy ties because they can loosen more easily, increasing the risk of accidental decannulation (dislodging the tracheostomy tube). The ties should be securely fastened with a non-quick-release knot.

Cut the old ties after the new ties are secured:This is a standard practice, but the order doesn't supersede the importance of proper tightness when securing the new ties.

Extend the client's neck while securing the ties:This is not the correct action. Hyperextending the client's neck during tracheostomy tie changes can cause discomfort and may compromise the integrity of the tracheostomy tube placement. The neck should be in a neutral position to maintain proper alignment.

Occupational therapist:While occupational therapists play a valuable role in stroke rehabilitation, they typically focus on activities of daily living (ADLs), upper extremity function, and adaptive strategies. In the context of frequent coughing during swallowing, the expertise of an SLP is more directly relevant to address potential dysphagia.

Physical therapist:Physical therapists primarily focus on mobility, strength, and balance. While they may be involved in stroke rehabilitation, the issue of coughing during swallowing is more aligned with the scope of practice of a speech-language pathologist.

Social worker:Social workers provide support for psychosocial and community-related issues. While they are crucial members of the interdisciplinary team, they may not have the specific expertise needed to address the swallowing difficulties experienced by the client after a stroke

Administer an antiemetic:Administering an antiemetic might be necessary to relieve nausea and vomiting, but it is not the first action. Before administering medications, it is essential to assess the client's condition and gather information about the underlying cause of the symptoms.

Offer pain medication:Offering pain medication is not the first action. The nurse needs to assess the client's condition, determine the cause of the pain, and gather more information before administering pain relief. Administering pain medication before a thorough assessment can mask important clinical signs and symptoms.

Palpate the abdomen:Palpating the abdomen is an important step in the assessment, but it should follow auscultation of bowel sounds. Palpation can be deferred if there is concern about possible inflammation (as in suspected appendicitis) to avoid causing further irritation.

Check that the client has a small gauge IV catheter in place:While it is important to have an appropriate-sized IV catheter for blood transfusions, checking the compatibility of the blood product with the client's blood type is the primary concern before initiating the transfusion. The IV catheter size becomes relevant after confirming compatibility.

Prime the client's primary IV tubing with lactated Ringer's:Priming the tubing with lactated Ringer's is not the first step. The initial focus should be on verifying the compatibility of the blood product with the client's blood type. After ensuring compatibility, the nurse can then prime the tubing with the appropriate blood product.

Confirm the identity of the client with the blood bank technician:Confirming the identity of the client with the blood bank technician is important, but it is not the first step before the start of the infusion. The immediate priority is to check the compatibility of the blood product with the client's blood type. Confirming the client's identity becomes crucial during the administration process.

Invasion of privacy:Invasion of privacy involves the unauthorized intrusion into an individual's personal matters. The nurse's statement does not relate to invading the client's privacy; it involves a threat related to the administration of medication.

Defamation:Defamation involves making false statements that harm the reputation of another person. The nurse's statement is not making false statements about the client but rather threatening a specific action if a behavior is not followed.

Battery:Battery occurs when there is intentional physical contact with another person without their consent. While the nurse's statement involves the administration of medication, the threat itself is considered assault. If the threat is carried out, and the medication is administered against the client's will, it would then be considered battery.

"You shouldn't worry about the future so you can concentrate on getting well.":This response dismisses the client's concerns and may make them feel invalidated. It implies that their worry is not justified and may hinder open communication about their feelings.

"If you work hard on your physical therapy, you won't need to worry.":While encouragement and motivation are essential, this response may come across as minimizing the client's emotional concerns. It focuses solely on the physical aspect of recovery and does not address the broader emotional and psychological aspects of the client's worry about the future.

"Why are you concerned even though everyone is here to help you?":This response might be perceived as judgmental or dismissive of the client's feelings. It could make the client feel defensive and hesitant to share their concerns. It does not encourage open communication or exploration of the client's emotions.

"Tell me more about your partner.":While understanding the client's feelings about their partner is important, the immediate concern is the client's statement expressing a desire to die. Therefore, focusing on the client's thoughts about self-harm (Option B) takes precedence in ensuring their safety.

"Why did you stop taking your medication?":While understanding the reasons behind medication non-compliance is important, the immediate concern is the client's current statement indicating suicidal ideation. Exploring the client's medication adherence can be addressed after addressing the acute safety concern.

"You should discuss these feelings with your provider.":This response might be seen as avoiding the client's immediate expression of distress. It is important for the nurse to directly assess the client's risk and initiate appropriate interventions rather than deferring the responsibility to another healthcare provider at this moment.

Schedule a support session for the client:While emotional support is essential for clients undergoing a laryngectomy, it is not the immediate priority in this situation. Assessing the client's ability to read and communicate is crucial for addressing their immediate needs and ensuring effective communication postoperatively.

Review the use of an artificial larynx with the client:While the use of an artificial larynx is an important aspect of communication after a total laryngectomy, it is not the priority. The nurse should first assess the client's current ability to read as it is a more immediate and accessible means of communication.

Explain the techniques of esophageal speech:Esophageal speech is another method of communication after a laryngectomy, but it is not always suitable for every individual. It requires specific skills and may not be the initial focus, especially if the client is not familiar with or interested in this technique. Assessing the client's reading ability is a more immediate concern.

Direct a fire extinguisher at the fire:While using a fire extinguisher is an essential action in controlling a small fire, it should come after the fire alarm has been activated. Alerting others to the fire and initiating the emergency response system take precedence to ensure a coordinated and safe response.

Place wet towels along the base of the door:Placing wet towels along the base of the door is a method to help prevent smoke from entering the room. However, in this situation, after ensuring the client's safety, the nurse should focus on activating the facility's fire alarm to alert others and initiate the emergency response.

Turn off any electrical equipment:While turning off electrical equipment is a generally sound practice in fire safety, it is not the immediate next action after moving the client to safety. Activating the fire alarm takes precedence as it initiates a coordinated response and alerts others to the emergency.

"I've never been the kind of person to ask others for help.":This statement suggests a reluctance to seek help, and it may indicate a struggle with the new situational role. Adaptation often involves a willingness to accept assistance and support from others when needed.

"I'm looking forward to being able to be independent again.":This statement indicates a positive attitude toward regaining independence, but it may not necessarily indicate full adaptation to the new situational role. The client is expressing a future orientation, and the actual adaptation will be evident when independence is achieved.

"I really don't know what I'm supposed to do all day.":This statement suggests confusion or uncertainty about the daily routine, which may indicate a lack of adjustment to the new living situation. Adaptation involves a sense of understanding and comfort with one's roles and activities.

Encourage the client to use a straw to take the medications:Using a straw may not be recommended for clients with dysphagia, as it can alter the normal swallowing process and increase the risk of aspiration. The focus should be on safe administration of medications without compromising the client's ability to swallow.

Give the client's medications between meals:The timing of medication administration is important, but the priority is the safe administration of medications, especially for clients with dysphagia. Administering medications between meals may not directly address the safety concerns related to swallowing.

Assist the client into semi-Fowler's position:While positioning is important, especially for clients with dysphagia, the administration of medications one at a time (Option A) takes precedence in ensuring the safety of the client's swallowing. Semi-Fowler's position may be beneficial, but it is not the primary action related to medication administration.

Urinary catheter care:Urinary catheter care is important for preventing infections and maintaining urinary function, but it is generally not as urgent as addressing respiratory distress. If the client is experiencing respiratory issues, addressing these concerns should take precedence.

Enteral feeding:While enteral feeding is essential for providing nutrition, it is not typically as urgent as addressing respiratory needs. If a client requires endotracheal suctioning for respiratory support, it should be prioritized over enteral feeding.

Wound irrigation:Wound irrigation is important for wound care, but it is generally not as time-sensitive as addressing respiratory needs. If the client's airway is compromised, it takes precedence over wound irrigation.

Administer the PN and fat emulsion separately:Administering the PN and fat emulsion separately is not a typical practice. Usually, PN formulations are prepared to include both macronutrients (carbohydrates and fat) in a single bag to provide a balanced nutritional profile. Administering them separately might lead to inconsistencies in the client's nutritional intake.

Change the PN infusion bag every 48 hr:The frequency of changing the PN infusion bag is not solely determined by time but rather by factors such as the stability of the solution, risk of contamination, and compatibility of the components. The specific recommendation for changing the PN bag should be based on institutional policies and the characteristics of the PN solution being used.

Obtain a random blood glucose daily:While monitoring blood glucose is important in clients receiving PN, obtaining a random blood glucose daily is not specific enough for managing the potential hyperglycemic effects of a 20% dextrose solution. Continuous glucose monitoring or more frequent and scheduled blood glucose checks may be necessary.

Obtain consent from the surgeon:The surgeon is not the appropriate person to obtain consent from in this situation. Informed consent should ideally come from the client or a legal surrogate decision-maker, depending on the circumstances. Surgeons are responsible for discussing the procedure with the patient or their authorized representative before surgery, but obtaining consent is not the nurse's role.

Contact the facility's ethics committee for guidance:While the ethics committee may provide guidance in complex ethical situations, the immediate concern in this emergency situation is to address the client's life-threatening condition. The nurse should prioritize actions that ensure the client receives timely and necessary medical care.

Keep the client stable until a family member arrives to give consent:While obtaining consent from a family member is ideal, waiting for consent can delay critical and time-sensitive interventions. In emergency situations, the priority is to provide necessary medical care promptly to stabilize the client. If there is no one available to give consent immediately, healthcare providers may proceed with necessary interventions to preserve life and limb.

Turn overhead lights to a bright setting:This is incorrect. The environment for postmortem care should be handled with respect and consideration for the family. Turning the lights to a bright setting may create an uncomfortable or clinical atmosphere. A calm and serene environment is more appropriate for this sensitive task.

Leave the client's eyes open until the family views the body:This is incorrect. It is customary to gently close the deceased person's eyes as part of postmortem care. Leaving the eyes open may be distressing for the family and does not contribute to creating a peaceful appearance.

Remove the client's dentures for their family to keep:This is incorrect. Dentures are typically returned to the family rather than kept by the family. The nurse should handle the removal of any personal items with sensitivity and respect, returning them to the family as appropriate.