Correct Answer: A,E

Rationale: Cutting the pouch opening 1/8 inch larger ensures a proper fit, preventing skin irritation. Using gauze is a practical tip but not a core instruction. A purple-blue stoma indicates poor blood flow, not healing, and requires medical attention. Povidone-iodine is too harsh; mild soap and water are recommended. Emptying the pouch at one-third full prevents leaks and maintains hygiene.

Correct Answer: B

Rationale: Refrigerating the solution before irrigation is not recommended. The solution should be at room temperature to avoid causing discomfort or vasoconstriction, which can impede the healing process. Administering an analgesic medication 5 minutes before starting irrigation is correct. This action helps manage the client's pain during the procedure, ensuring comfort and compliance. Using one pair of gloves for both dressing removal and irrigation is incorrect. The nurse should use separate pairs of gloves to prevent cross-contamination and maintain aseptic technique. Using a syringe with a catheter for wound irrigation is correct practice. This method allows for controlled and directed irrigation, ensuring the wound is properly cleaned.

Correct Answer: B

Rationale: Electrical wires secured to baseboards are generally not considered a significant fall risk. Properly secured wires reduce the likelihood of tripping hazards compared to loose or exposed wires.
Therefore, this is not a primary concern for fall risk. Taking antihypertensive medication can increase the risk of falls, especially in older adults. These medications can cause orthostatic hypotension, a condition where blood pressure drops significantly upon standing, leading to dizziness and an increased risk of falling. This makes it a critical factor to consider in fall risk assessments. Wearing rubber-sole shoes is typically recommended to prevent falls because they provide good traction and reduce the risk of slipping. However, if the soles are too thick or bulky, they can catch on carpets or other surfaces, potentially causing trips. Generally, rubber-sole shoes are considered safer than other types of footwear. A visual acuity of 20/40 indicates some level of visual impairment, but it is not severe. While reduced visual acuity can contribute to fall risk, it is not as significant as the risk posed by medications that affect blood pressure. Visual impairments should still be addressed, but they are not the most immediate concern in this context.

Correct Answer: B

Rationale: Telling the client about the benefits of the surgery might seem helpful, but it does not address the client's immediate concern. The client has expressed a clear decision to refuse the surgery, and the nurse must respect this decision by informing the surgeon. This approach aligns with the ethical principle of respecting patient autonomy. Letting the client know that their surgeon will be notified of their decision is the correct action. This respects the client's autonomy and ensures that the surgeon is aware of the client's wishes. It also allows for further discussion between the client and the surgeon, where the client can receive more detailed information and support. Reassuring the client that it is expected to be nervous before surgery is supportive but does not address the client's refusal. While it is important to acknowledge the client's feelings, the nurse must also take appropriate steps to respect the client's decision and inform the surgeon. Informing the client that it is too late to stop the surgery is incorrect and unethical. Patients have the right to refuse treatment at any time, and it is the nurse's duty to respect and facilitate this decision.

Correct Answer: D

Rationale: Documenting the indications for using wrist restraints is an important step in the process, but it is not the first action the nurse should take. Documentation ensures that there is a clear rationale for the use of restraints and helps in maintaining legal and ethical standards. However, before documenting, the nurse must explore and attempt less restrictive alternatives to ensure that restraints are truly necessary. Obtaining a prescription for restraints from the provider is a crucial step, as restraints should only be used with a valid order from a healthcare provider. This ensures that the use of restraints is medically justified and that the provider is aware of the client's condition. However, before seeking a prescription, the nurse must first attempt less restrictive alternatives to manage the client's behavior. Explaining the procedure to the client and their family is an important step in obtaining informed consent and maintaining transparency. However, it should be done after the nurse has determined that less restrictive alternatives are not effective and that restraints are necessary. Attempting less restrictive alternatives is the first action the nurse must take. This approach aligns with ethical and legal guidelines that emphasize the use of the least restrictive measures to ensure the client's safety. Alternatives may include verbal de-escalation, environmental modifications, or the use of less restrictive devices. Only if these measures fail should the nurse consider using restraints.