Correct Answer: B

Rationale: The correct answer is B: Let the client know that their surgeon will be notified of their decision. This action respects the client's autonomy and ensures that the healthcare team is informed about the client's decision in a timely manner. It allows for further discussion or exploration of alternatives before proceeding with the surgery.


Choice A: Telling the client about the benefits of the surgery may be considered coercive and does not address the client's concerns or wishes.


Choice C: Reassuring the client without acknowledging their concerns may invalidate their feelings and does not address the client's decision to refuse surgery.


Choice D: Informing the client that it is too late to stop the surgery disregards the client's autonomy and right to make decisions about their own healthcare.

Correct Answer: D

Rationale: The correct answer is D: Attempt less restrictive alternatives. Before using wrist restraints on a client, the nurse must first try less restrictive measures to ensure the client's safety and well-being. This involves exploring alternative methods to prevent the client from pulling out the IV catheter, such as using soft restraints, diversional activities, or involving family members in supervision. This approach aligns with the principles of patient autonomy and least restrictive intervention, promoting the client's dignity and minimizing the risk of physical and psychological harm. Documenting the indications for using restraints (choice
A), obtaining a prescription (choice
B), and explaining the procedure (choice
C) are important steps but should come after attempting less restrictive measures.

Correct Answer: A

Rationale: The correct answer is A: Wait 5 minutes between the administration of each medication. This is important to prevent dilution or washout of the first medication by the second one. Administering multiple drops simultaneously can lead to reduced effectiveness of both medications. Waiting between administrations allows each medication to be absorbed properly.
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Choice B is incorrect because asking the client to close their eyes tightly after instillation may not be necessary for all types of ophthalmic drops.
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Choice C is incorrect as the distance of holding the dropper is not crucial for the administration of the drops.
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Choice D is incorrect as massaging the client's eyelids after instillation is not a standard practice and may not be safe for all types of ophthalmic medications.

Correct Answer: C

Rationale: The correct answer is C: Collect the sputum specimen in the morning. This is because sputum is usually more concentrated and easier to collect in the morning due to the buildup overnight. Using sterile gloves (
Choice
A) is not necessary for sputum collection unless the patient has a compromised immune system. Obtaining the specimen after mouthwash (
Choice
B) can alter the normal flora in the mouth. Placing the specimen in a clean container (
Choice
D) is not sufficient, as it should be placed in a sterile container for accurate results.

Correct Answer: C

Rationale: The correct answer is C: Clean from the incision to the surrounding skin. This instruction is crucial to prevent introducing any pathogens into the wound. Cleaning from the incision site outward helps minimize the risk of contamination. Option A is incorrect as changing the dressing too frequently can disrupt the wound healing process. Option B is incorrect as tincture of benzoin can cause skin irritation and is not recommended for incision sites. Option D is incorrect as sterile gloves are not necessary for routine dressing changes unless in a sterile environment.