Correct Answer: A

Rationale: The correct action for the nurse to include in the plan of care for an older adult at risk for falls is to lock beds and wheelchairs when not in use. This measure is crucial for preventing falls and ensuring patient safety in healthcare settings. Administering sedatives at bedtime (Choice B) is not recommended as it does not address the underlying risk factors for falls and may increase the risk of injury. Providing information about home safety checks (Choice C) is important for fall prevention in the home environment but is not directly related to healthcare settings. Teaching balance and strengthening exercises (Choice D) is beneficial for fall prevention but may not be suitable for all older adults at risk for falls, especially in acute care settings.

Correct Answer: C

Rationale: In a postoperative client, decreased urine output is a crucial finding as it can indicate impaired kidney function or inadequate fluid balance. Prioritizing assessment and intervention for decreased urine output is essential to prevent complications like acute kidney injury. Elevated temperature, low blood pressure, and increased heart rate are also important, but they may not be as urgent or directly related to kidney function in a postoperative client.

Correct Answer: C

Rationale: The correct answer is C because testicles should be uniform in consistency when performing a self-exam, and any lumps or abnormalities should be reported. Choice A is incorrect as testicular self-examinations should be performed monthly, not weekly. Choice B is incorrect because the epididymis should be included in the examination. Choice D is incorrect because a warm shower helps relax the scrotum, making the exam easier to perform.

Correct Answer: D

Rationale: Grape juice is the correct choice for a clear liquid diet because it is a liquid that is transparent and does not contain any solid particles. Lemon sherbet, milkshake, and vanilla ice cream are not appropriate for a clear liquid diet as they all contain solid particles or are not in liquid form.

Correct Answer: C

Rationale: The correct answer is monitoring the respiratory rate. Morphine can depress respiratory function, leading to respiratory depression or arrest. Therefore, closely monitoring the client's respiratory rate is crucial to detect any signs of respiratory distress. While blood pressure, heart rate, and temperature are important assessments, in this scenario, respiratory rate takes precedence due to the potential respiratory complications associated with morphine administration.