🟢 Oral care is a basic, routine, noninvasive activity of daily living (ADL) that falls within the scope of practice of an AP.

🟢 The nurse is responsible for assessing, planning, and evaluating, while the AP can safely perform assigned direct care tasks like hygiene.

🟢 Delegating oral care allows the nurse to focus on higher-level tasks such as assessments, teaching, and medication administration.

🟢 The nurse must still supervise and ensure that the care is completed appropriately but does not need to personally perform this task.

🟢 Therefore, assisting a client with oral care is an appropriate and safe task to delegate to an AP.

Provide instructions about client care to a family member over the telephone

🟢 Providing instructions about client care involves teaching, explanation, and clarification, which are nursing responsibilities requiring professional judgment.

🟢 Telephone teaching often requires assessment of understanding, adjustment of instructions, and consideration of the client's clinical condition.

🟢 APs do not have the scope to provide formal teaching or care instructions, especially over the phone.

🟢 Delegating this to an AP risks miscommunication and incomplete or inaccurate teaching.

🟢 Thus, the nurse must not delegate client-care instructions to the AP.

Determine if the PRN pain medication administered 30 min ago has helped

🟢 Evaluating whether a PRN pain medication was effective is part of the nursing process (evaluation).

🟢 This requires assessment skills, including reviewing pain scales, observing nonverbal cues, and integrating clinical context.

🟢 APs can report observations, but they cannot be responsible for determining medication effectiveness or altering care based on that evaluation.

🟢 The responsibility for evaluating the client’s response to medications lies with the licensed nurse.

🟢 Therefore, the nurse should not delegate this evaluation task to an AP.

Teach a client how to measure their own blood pressure

🟢 Teaching is a core RN responsibility that requires assessing readiness to learn, tailoring explanations, and ensuring comprehension.

🟢 Teaching a client to measure their own blood pressure may impact long-term self-management and requires accurate demonstration and validation.

🟢 APs can reinforce previously taught information if directed, but they should not be responsible for initial teaching.

🟢 Delegating teaching to an AP could result in incomplete or incorrect education.

🟢 Thus, teaching blood pressure self-monitoring must be done by the nurse, not delegated.

⭐ Keeping the head of the bed (HOB) elevated 30°–45° during and after feedings helps prevent aspiration of gastric contents.

⭐ Elevation for at least 30–60 minutes after feeding decreases the risk that formula will reflux and be aspirated into the lungs.

⭐ Aspiration can lead to pneumonia, respiratory compromise, and serious complications in vulnerable clients.

⭐ Maintaining HOB elevation is a standard safety measure in enteral feeding protocols.

⭐ Therefore, keeping the HOB at 45° for 1 hour after feedings demonstrates correct understanding of aspiration prevention.

Instills 100 mL of air into the NG tube after checking for residual

⭐ Instilling 100 mL of air into the NG tube is excessive and not a recommended practice.

⭐ Older techniques used small amounts of air with auscultation, but this is unreliable and outdated compared to measuring pH or aspirate characteristics.

⭐ Large volumes of air can cause gastric distention and discomfort.

⭐ Verification of NG tube placement and patency should follow evidence-based methods like pH testing of gastric aspirate and x-ray confirmation initially.

⭐ Thus, instilling 100 mL of air does not indicate correct technique.

Flushes the NG tube with 0.9% sodium chloride irrigation every 2 hr

⭐ Routine flushes are typically done with sterile or tap water, depending on policy and client condition, not standardly with 0.9% sodium chloride every 2 hr.

⭐ Excessive sodium chloride flushing could potentially contribute to electrolyte imbalances in some clients.

⭐ The timing and solution for flushing are usually based on facility protocol, type of feeding, and medication administration needs.

⭐ The key safe practice for aspiration prevention is positioning, not frequent saline irrigation.

⭐ Therefore, this action does not specifically demonstrate correct enteral feeding technique.

Adds 20 mL of blue dye to each feeding to help detect aspiration

⭐ Adding blue dye to enteral feedings is no longer recommended because it has been associated with serious adverse effects and is not reliable for detecting aspiration.

⭐ Blue dye can cause metabolic complications and does not consistently appear in respiratory secretions even when aspiration occurs.

⭐ Aspiration detection should rely on clinical assessment, monitoring for respiratory changes, and prevention strategies like proper positioning.

⭐ This outdated practice is considered unsafe and not evidence-based.

⭐ Thus, adding blue dye to feedings does not indicate correct practice.

🟣 Methadone is a long-acting opioid agonist used in medication-assisted treatment for opioid use disorder.

🟣 As an opioid, it commonly causes sedation, especially early in treatment or after dose changes.

🟣 Clients should be taught to avoid driving or operating heavy machinery until they know how methadone affects them.

🟣 Other opioid effects such as respiratory depression, constipation, and potential QT prolongation should also be monitored.

🟣 Therefore, stating that sedation is a common adverse effect is accurate and important teaching.

“If you suspect you are pregnant, stop taking this medication."

🟣 Stopping methadone abruptly during pregnancy can cause withdrawal, which may be harmful to both the birthing parent and fetus.

🟣 Methadone is actually commonly used as standard of care for opioid use disorder in pregnancy, under careful supervision.

🟣 Instead of stopping, the client should notify their provider so treatment can be adjusted and monitored safely.

🟣 Sudden cessation can increase the risk of relapse, overdose, and fetal distress.

🟣 Thus, this instruction is unsafe and incorrect.

"You cannot become physically dependent on this medication."

🟣 Methadone is an opioid, and clients can become physically dependent on it.

🟣 The goal of methadone treatment is harm reduction and stabilization, not elimination of physical dependence.

🟣 Dependence is managed through controlled dosing under a structured program, reducing risks associated with illicit opioid use.

🟣 Misleading clients to believe they cannot become dependent undermines informed consent and trust.

🟣 Therefore, this statement is false and should not be part of patient teaching.

"If you forget a dose, you can double your next dose."

🟣 Doubling the next methadone dose greatly increases the risk of overdose and respiratory depression.

🟣 Methadone has a long half-life, and doses are carefully titrated to avoid toxicity.

🟣 The client should be instructed to contact the clinic or provider if they miss a dose, rather than self-adjust dosing.

🟣 Safe opioid management never involves “doubling up” missed doses.

🟣 Thus, this statement is dangerous and incorrect.

🔶 In crisis intervention, after physical safety is ensured, the nurse’s first priority is to assess the client’s perception of the event and its impact.

🔶 Different clients experience the same event differently; understanding the client’s subjective view guides all further interventions.

🔶 This assessment helps identify specific emotional responses, coping mechanisms, and areas of greatest distress.

🔶 Without this information, referrals and support may be mismatched to the client’s actual needs.

🔶 Therefore, the nurse should first determine the client’s perception of the personal impact of the crisis before implementing other steps.

Assist the client with contacting individuals from the client's support system

🔶 Mobilizing social support is an important part of crisis intervention, but it comes after assessment of the client’s perceptions and coping.

🔶 Some clients may feel ashamed, conflicted, or unsafe contacting certain support people, which the nurse will learn only by assessment first.

🔶 Acting before understanding the client’s feelings could add to their stress or sense of loss of control.

🔶 Once the client’s perceptions and preferences are clarified, the nurse can collaboratively identify appropriate support persons.

🔶 Thus, contacting the support system is important but not the first step after safety is ensured.

Give the client information about available community resources for shelter

🔶 Providing resource information is necessary, but it is part of planning and intervention, which comes after assessment in the nursing process.

🔶 The nurse should first understand the client’s immediate emotional state, priorities, and coping capacity.

🔶 Resource needs may vary depending on whether the client has family options, financial means, or particular vulnerabilities.

🔶 If the nurse skips assessment, the support offered could be inefficient or overwhelming.

🔶 Therefore, community resource information is not the first step after ensuring safety.

Suggest the client obtain mental health counseling

🔶 While mental health counseling is often beneficial after a major disaster, the nurse must first assess the client’s perception and needs.

🔶 Immediately suggesting counseling without understanding the client’s experience may feel premature or invalidating.

🔶 The client may need basic stabilization, support, and problem-solving before considering formal therapy.

🔶 Counseling referral fits into a later phase of intervention and follow-up, not the initial step after safety.

🔶 Thus, suggesting counseling is helpful but not the first action in crisis care.

💬 In the orientation phase, the nurse and client focus on building trust, defining roles, and setting the structure of the relationship.

💬 A key task of this phase is to establish the time frame and termination date so the client understands the boundaries and expectations.

💬 Being clear about how long therapy will last helps reduce anxiety and fosters predictability and reliability, which build trust.

💬 It also supports the client in recognizing that the relationship is professional and time-limited, not social.

💬 Therefore, establishing the termination date of therapy is an appropriate action to build trust during the orientation phase.

Encourage the client's problem-solving abilities.

💬 Encouraging problem-solving abilities is a major focus of the working phase, when the client and nurse collaborate to address problems and implement interventions.

💬 In the very first meeting, the priority is not solving problems but building rapport, explaining roles, and clarifying expectations.

💬 Prematurely emphasizing problem-solving may make the client feel rushed or pressured, which can hinder trust.

💬 The nurse should first ensure the client feels safe and understood before actively pushing toward solutions.

💬 Thus, while important later, encouraging problem-solving is not the primary orientation-phase task.

Discuss the client's previous experience with loss.

💬 Exploring previous experiences with loss is more characteristic of the working phase, where the focus is on processing feelings and experiences.

💬 In the initial orientation meeting, the nurse’s goal is primarily to introduce the relationship framework and set a foundation of trust and structure.

💬 Deep exploration of prior losses can be emotionally intense and may be better handled after trust has been firmly established.

💬 The nurse may acknowledge the current loss but should not yet delve deeply into past grief histories as the central task.

💬 Therefore, this is more appropriate later in therapy, not as the first orientation priority.

Promote the client's self-esteem.

💬 Promoting self-esteem is an ongoing goal, especially in the working phase, where the client is encouraged to develop coping skills and self-worth.

💬 In the first meeting, the primary aim is role clarification, purpose of meetings, and establishing boundaries and trust.

💬 While the nurse will always communicate respect and unconditional positive regard, structured self-esteem work comes later.

💬 Jumping immediately into “self-esteem promotion” without a clear framework may feel superficial or premature.

💬 Thus, self-esteem promotion is important but not the central orientation-phase task compared to setting the termination date and structure.

🧪 The pH 7.30 is acidotic (normal 7.35–7.45), indicating an acidemia.

🧪 The PaCO₂ is 54 mm Hg, which is elevated, indicating a primary respiratory acidosis because CO₂ retention is causing the acidity.

🧪 The HCO₃ is 26 mEq/L, which is within the normal range, showing that the kidneys have not yet compensated significantly.

🧪 When the pH is abnormal and the compensatory system (HCO₃) is still normal, this is categorized as uncompensated.

🧪 Therefore, these ABG values reflect uncompensated respiratory acidosis in a client with COPD.

Uncompensated metabolic acidosis

🧪 Metabolic acidosis is characterized by a low HCO₃ (below 21 mEq/L), which is not present here since HCO₃ is 26.

🧪 In metabolic acidosis, the primary problem is a loss of bicarbonate or gain of acid, not CO₂ retention.

🧪 Here, the key abnormality is high PaCO₂, pointing clearly to a respiratory origin of the acidosis.

🧪 The normal HCO₃ level means the metabolic system is not the primary cause of the pH disturbance.

🧪 Thus, this ABG pattern does not match metabolic acidosis.

Compensated respiratory acidosis

🧪 In compensated respiratory acidosis, the pH would be closer to normal because the kidneys would have increased HCO₃ to offset high CO₂.

🧪 Here, the pH is still clearly acidotic (7.30) and the HCO₃ is normal, indicating compensation has not yet occurred or is minimal.

🧪 Full compensation requires HCO₃ above normal (e.g., >28) in a chronic respiratory acidosis.

🧪 Since both pH and PaCO₂ are abnormal but HCO₃ is normal, this is uncompensated, not compensated.

🧪 Therefore, compensated respiratory acidosis is not the correct interpretation.

Compensated metabolic acidosis

🧪 Metabolic acidosis would show a low HCO₃ and compensatory low PaCO₂ (hyperventilation), which is the opposite of this ABG.

🧪 In this case, PaCO₂ is high, not low, immediately ruling out a primary metabolic acidosis pattern.

🧪 Compensation for metabolic acidosis would involve respiratory alkalosis, not respiratory acidosis.

🧪 The normal bicarbonate level and elevated CO₂ firmly indicate a respiratory primary problem.

🧪 Thus, the ABG does not reflect compensated metabolic acidosis.

🍬 Hypoglycemia often presents with neurogenic and neuroglycopenic symptoms, such as irritability, shakiness, confusion, and anxiety.

🍬 The brain depends on glucose as its primary fuel, so low blood glucose can quickly alter mood and behavior, including irritability.

🍬 Clients may also experience sweating, tremors, palpitations, and hunger along with irritability.

🍬 Recognizing early behavior changes like irritability allows the client to treat hypoglycemia promptly with rapid-acting carbohydrates.

🍬 Therefore, irritability is a classic and important manifestation of hypoglycemia.

Increased urination

🍬 Increased urination (polyuria) is a hallmark sign of hyperglycemia, not hypoglycemia.

🍬 When blood glucose is high, the kidneys excrete the excess glucose, resulting in osmotic diuresis and polyuria.

🍬 This is often accompanied by polydipsia and polyphagia, especially in uncontrolled diabetes or DKA.

🍬 Hypoglycemia typically does not cause increased urination, but instead causes acute neurologic and adrenergic symptoms.

🍬 Thus, increased urination points more toward hyperglycemia, not hypoglycemia.

Vomiting

🍬 Vomiting is more commonly associated with severe hyperglycemia, DKA, or gastrointestinal illness, rather than simple hypoglycemia.

🍬 In DKA, metabolic acidosis and GI irritation often lead to nausea and vomiting, along with abdominal pain.

🍬 Hypoglycemia primarily produces neurologic and autonomic symptoms, not GI upset as the main feature.

🍬 While a person could vomit for many reasons, it is not considered a core early sign of hypoglycemia.

🍬 Therefore, vomiting is not the best indicator of hypoglycemia for teaching purposes.

Facial warmth

🍬 Facial warmth is a nonspecific symptom and is not a classic sign of either hypoglycemia or hyperglycemia.

🍬 Students and clients should focus on recognizable patterns such as shakiness, sweating, confusion, irritability, and palpitations for hypoglycemia.

🍬 Using vague symptoms like facial warmth may confuse recognition and delay proper treatment.

🍬 Clear teaching centers on well-established signs that strongly correlate with low blood glucose.

🍬 Thus, facial warmth is not an appropriate key symptom to teach for hypoglycemia.

🩹 After proper skin preparation, the nurse should apply the skin barrier and hold it in place to allow warmth and pressure to activate the adhesive.

🩹 Holding the barrier in place for about 30 seconds helps ensure a good seal, which prevents leakage and protects the surrounding skin.

🩹 A secure seal is essential to prevent skin breakdown, odor, and pouch leakage, all of which affect comfort and quality of life.

🩹 This step is a standard part of correct two-piece colostomy pouch application technique.

🩹 Therefore, placing the barrier and holding it for 30 seconds is an appropriate and evidence-based action.

Cleanse the skin at the stoma site with povidone-iodine for 15 seconds.

🩹 The peristomal skin should be cleansed with mild soap and water or just warm water, not povidone-iodine, which can irritate the skin.

🩹 Harsh antiseptics can cause dryness and damage to the delicate skin around the stoma.

🩹 Residue from antiseptics may also interfere with the adhesion of the skin barrier.

🩹 The goal is to keep the skin intact, clean, and dry, not sterile, since the stoma is not a sterile site.

🩹 Thus, povidone-iodine cleansing is not recommended for routine colostomy care.

Dampen the skin before applying the skin barrier and ostomy pouch.

🩹 The peristomal skin should be completely dry before applying the skin barrier and pouch to ensure optimal adhesion.

🩹 Moist or damp skin will prevent the barrier from sticking well, increasing the risk of leakage and skin breakdown.

🩹 Drying the area thoroughly with a soft towel or gauze is a key step in preparation.

🩹 Applying to damp skin contradicts best practice for ostomy appliance adherence.

🩹 Therefore, dampening the skin is incorrect technique.

Cut the skin barrier opening 0.6 cm (0.24 in) larger than the stoma.

🩹 The barrier opening should usually be cut about 1/8 to 1/16 inch (2–3 mm) larger than the stoma to limit exposed skin.

🩹 Cutting the opening 0.6 cm (about 6 mm) larger leaves too much skin exposed, increasing risk of irritation from effluent.

🩹 Excess exposure to stool can cause chemical irritation, breakdown, and discomfort.

🩹 A close fit helps protect the skin while avoiding pressure directly on the stoma.

🩹 Thus, 0.6 cm larger is too big, making this an incorrect practice.