Correct Answer: B

Rationale: The correct answer is B: Remove one restraint at a time. This is the appropriate action because it allows the nurse to maintain control over the client while ensuring safety. By removing one restraint at a time, the nurse can assess the client's behavior and determine if they are calm enough to have both restraints removed. This approach also minimizes the risk of the client becoming agitated or aggressive when both restraints are removed simultaneously.

A: Tying the restraints to the side rail restricts the client's movement and can lead to injury.
C: Securing restraints with a square knot may make it difficult to quickly remove them in case of an emergency.
D: Removing the restraints every 3 hours does not address the immediate safety concerns and may not be necessary based on the client's behavior.

Correct Answer: B

Rationale: The correct answer is B: Dilute each crushed medication with sterile water. This is the correct action because mixing medications together in a single syringe (
Choice
A) may cause drug interactions. Flushing the NG tube with sterile water before administration (
Choice
C) is important for tube patency but not specific to medication administration. Combining the medications with the formula in the feeding bag (
Choice
D) may affect the feeding formula's effectiveness. Diluting each crushed medication with sterile water ensures proper dispersion and absorption of the medications without compromising the feeding tube or formula.

Correct Answer: C

Rationale: The correct answer is C because providing written information about advance directives prior to signing allows the client to make an informed decision. This ensures that the client understands the purpose and implications of advance directives, empowering them to make choices consistent with their values and preferences.
Choice A is incorrect because it is the client, not the provider, who should sign advance directives.
Choice B is incorrect as the presence of the partner is not a requirement for signing advance directives.
Choice D is incorrect as signing advance directives is not mandatory but a personal choice.

Correct Answer: C

Rationale: The correct action for the nurse to take first is to obtain the client's vital signs (
Choice
C). This is crucial to assess the client's response to the IV bolus, including monitoring for signs of fluid overload or other adverse effects. Vital signs such as blood pressure, pulse rate, respiratory rate, and temperature provide important information on the client's current status. Documenting the fluid infusion (
Choice
A) and reporting the incident to the unit manager (
Choice
D) are important steps but should follow the immediate assessment of the client's condition. Completing an incident report (
Choice
B) should also be done after ensuring the client's safety and well-being.

Correct Answer: A,B,D

Rationale:
Correct
Answer: A, B, D


Rationale:
A: Having a fire escape plan with the family ensures preparedness in case of a fire emergency.
B: Checking medication expiration dates is crucial to ensure they are safe and effective for use.
D: Using grab bars when getting in and out of the bathtub helps prevent falls and promotes safety.

Incorrect

Choices:
C: Setting the hot water heater to 140 degrees Fahrenheit is too hot and can cause burns.
E: Applying tape over frayed areas of electrical cords is not safe and can lead to electrical hazards.