Correct Answer: A

Rationale: Applying a bath blanket between the client and a cooling blanket regulates temperature comfortably. Ice packs risk localized cold injury, alcohol-water baths are outdated and unsafe, and heavy blankets can increase fever. Antibiotics are inappropriate without evidence of bacterial infection.

Correct Answer: A

Rationale: A gastric residual of 300 mL at the end of the shift is unexpected, as residuals exceeding 500 mL every 6 hours may indicate poor gastric emptying or intolerance to feeding, requiring further assessment. Weight gain is expected, a blood glucose level of 110 mg/dL is normal, and one episode of diarrhea is not uncommon with enteral feeding. Abdominal distension would be unexpected but is not listed as a finding here.

Correct Answer: B

Rationale: Placing the client in a private room prevents MRSA spread, as it requires contact precautions. An N95 mask is not needed, gloves are removed before the gown, and visitors do not need masks unless specified. Alcohol-based hand sanitizer is less effective against MRSA; soap and water are preferred.

Correct Answer: D

Rationale: Assessing peripheral pulses first ensures that restraints are not compromising circulation, which could lead to tissue damage. Elimination, comfort, skin integrity, and respiratory status are important but secondary to circulation.

Correct Answer: D

Rationale: Determining whether the client can afford insulin supplies ensures access to necessary treatment, preventing non-compliance. Other actions (reconciliation form, education materials, specialist contact, follow-up appointment) follow once affordability is confirmed.