🩹 The PN should report the client’s request for an analgesic prescription because pain after a surgical wound dressing change may require assessment and possible adjustment of pain management.

🩹 The healthcare provider should be notified when the client reports uncontrolled or inadequately managed pain, especially after a major procedure such as a colon resection.

🩹 Effective pain control promotes healing, mobility, deep breathing, and participation in recovery activities.

🩹 The PN cannot independently prescribe medication, so the request for additional pain medication must be communicated to the healthcare provider.

🩹 The nurse should assess the pain severity, characteristics, and any associated findings before reporting.

🩹 Unmanaged postoperative pain can negatively affect recovery and may indicate a need for further intervention.

Identify problems from the assessment data

🩺 Identifying problems is part of the diagnosis phase of the nursing process.

🩺 After collecting assessment information, the nurse analyzes the data to identify patient problems, needs, and priorities.

🩺 This step guides the development of appropriate nursing interventions.

Assess the result of the interventions

🩺 Evaluating the effectiveness of interventions is a key step in the nursing process.

🩺 The nurse determines whether the patient’s condition improved, remained the same, or requires changes in the plan of care.

🩺 Evaluation ensures that care remains safe and effective.

Collect history, assessment data, and diagnostics

🩺 Data collection is the assessment phase of the nursing process.

🩺 The nurse gathers information from the patient history, physical examination, laboratory results, and diagnostic findings.

🩺 Accurate assessment provides the foundation for identifying problems and planning care.

Carry out the interventions or tasks

🩺 Carrying out interventions is the implementation phase of the nursing process.

🩺 The nurse performs planned actions such as administering medications, providing treatments, and educating the patient.

🩺 Implementation is necessary to address identified patient problems.

🦺 The PN should review the posted mobility algorithm because it provides evidence-based guidance for safely transferring clients with limited movement.

🦺 Mobility algorithms help healthcare workers determine the safest method and equipment needed based on the client’s mobility level, strength, and ability to participate.

🦺 Using the correct transfer technique reduces the risk of falls, client injury, and healthcare worker musculoskeletal injuries.

🦺 Clients with limited mobility may require devices such as gait belts, transfer aids, or mechanical lifts depending on their condition.

🦺 The nurse should always assess the client’s ability before attempting movement or transfer.

🦺 Following facility-approved transfer procedures promotes safe, consistent care.

🦺 Therefore, reviewing the mobility algorithm is the safest action for transferring a client with limited movement.

🫁 Preoxygenation is performed first to increase oxygen reserves and reduce the risk of hypoxia during suctioning.

🫁 The suction machine is turned on before suction is applied to ensure the equipment is ready.

🫁 Covering the suction control with the thumb activates suction only when needed, preventing unnecessary airway trauma.

🫁 The catheter is advanced gently until resistance is met, then withdrawn slightly before applying suction to avoid injury to the tracheal mucosa.

🫁 Rotating the catheter while withdrawing allows secretions to be removed more effectively from the airway walls.

🫁 Suction should be limited to no more than 10 seconds per pass to prevent oxygen deprivation and airway irritation.

🫁 Therefore, the correct sequence is:

Preoxygenate → Turn on suction → Apply suction control → Advance catheter → Rotate catheter → Remove catheter.

📝 B is the best documentation because it describes the client’s response to ambulation, including the activity performed, safety intervention, and an objective assessment finding.

📝 Effective nursing documentation should include specific, measurable, and objective data rather than vague statements.

📝 The statement records how long the client was active (5 minutes), confirms safety measures (call bell within reach), and provides an assessment finding (respirations 22/minute).

📝 Respiratory response after activity is important in older adults because it helps evaluate tolerance to exertion and functional status.

📝 Documentation should demonstrate whether the nursing intervention achieved the desired outcome and whether further monitoring is needed.

📝 Including safety measures also shows that appropriate fall-prevention actions were maintained after ambulation.

📝 Therefore, this entry best evaluates the client’s response to the nursing intervention.

💬 The statement “I see that you are upset and crying” is the most therapeutic response because it uses acknowledgment and validation of the client’s emotions.

💬 Therapeutic communication begins by recognizing the client’s feelings without judgment or trying to immediately solve the problem.

💬 This response shows empathy and encourages the client to express concerns in a safer and more open manner.

💬 The PN is acknowledging the client’s emotional state while allowing the client control over how much they want to share.

💬 Validation can help reduce anxiety, anger, and distress by showing the client that their feelings are being heard.

💬 A calm, supportive response is more likely to build trust and improve the nurse-client relationship.

💬 Therefore, the best therapeutic response is “I see that you are upset and crying.”

🔒 The PN should complete the medication administration process first because medication preparation and administration require the nurse’s full attention to maintain patient safety and prevent medication errors.

🔒 Interruptions during medication administration increase the risk of errors such as giving the wrong medication, wrong dose, or wrong patient.

🔒 The roommate’s request is important, but it is not an emergency and can safely wait until the PN completes the medication task.

🔒 The PN should maintain focus while using the electronic medication administration record (eMAR) to verify and document medications correctly.

🔒 After completing the medication process, the PN can assist the roommate or delegate the task appropriately.

🔒 Safe nursing practice requires prioritizing actions that prevent immediate harm before addressing nonurgent requests.

🔒 Therefore, the PN should finish medication administration and then assist the roommate.

📝 The PN should document the time the medication was actually administered and the reason for the delay because this provides an accurate legal record of care.

📝 Documentation should include objective facts, such as the client being unavailable because they were transported off the unit for a test.

📝 Accurate documentation supports continuity of care and allows other healthcare team members to understand why the medication was delayed.

📝 The nurse should avoid documenting opinions, blame, or unnecessary details.

📝 Medication administration records should reflect the actual administration time rather than the scheduled time if the medication was given late.

📝 Clear documentation helps maintain patient safety and provides legal protection for the nurse and healthcare facility.

📝 Therefore, the correct action is to document the time and reason for the delayed medication administration.

🚿 A condom catheter is an external urinary device placed over the penis, and daily care includes removing the device and cleansing the penis with soap and water.

🚿 Removing the condom allows the PN to assess the skin for irritation, breakdown, redness, swelling, or infection.

🚿 Proper cleansing helps prevent skin complications and urinary tract infections while maintaining hygiene.

🚿 After cleansing and drying the penis, a new condom catheter may be applied according to facility procedure.

🚿 The skin should be completely dry before reapplication to improve adhesion and prevent moisture-related skin problems.

🚿 Regular assessment is important because prolonged use of external catheters can cause skin irritation or injury.

🚿 Therefore, removing the condom catheter and cleansing the penis with soapy water is the appropriate action.