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: C

Rationale: Providing written information about advance directives ensures the client understands their options for medical decision-making. Signing is not mandatory, providers do not sign directives, and a partner’s presence is not required. Advance directives do not expire annually.

Correct Answer: C

Rationale: Wearing a mask when outside the room is crucial for a client undergoing an allogeneic stem cell transplant due to their immunocompromised state, protecting against infections. Visitors wearing gowns is secondary, semi-private rooms are avoided to reduce infection risk, and negative-airflow rooms are used to protect others, not the patient. Daily antibiotics are not standard unless infection is present.

Correct Answer: A

Rationale: The client’s belief that education will meet their needs aligns with self-efficacy theory, enhancing motivation to learn. External explanations, family approval, empathy, or fear of needles are less effective motivators.

Correct Answer: C

Rationale: A decreased sense of balance is common in older adults due to age-related changes in the vestibular system, increasing fall risk. Pain sensation may decrease, sleep patterns often fragment, incontinence is not exclusively nighttime, and muscle mass typically decreases with age.