Correct Answer: C

Rationale: The correct answer is C: "Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom'." This statement should be included in the documentation as it provides firsthand information from the client about the circumstances leading to the fall, ensuring accuracy and clarity. It also demonstrates the client's perspective and helps in understanding the root cause of the fall. Other choices are incorrect because: A blames the assistive personnel without evidence, B only addresses the absence of visible injuries, and D is unrelated to the specific details of the fall incident.

Correct Answer: A

Rationale: The correct answer is A: Apply pressure to the lacrimal punctum after administering the drops. This action helps prevent systemic absorption of the medication and reduces the risk of side effects. By applying pressure to the lacrimal punctum, the nurse can minimize the drainage of the medication into the nasolacrimal duct, which can lead to the medication being absorbed systemically. Positioning the child side-lying or flushing the eye with saline solution before administering the drops are unnecessary steps for administering eye drops to a child. Wiping from the outer to the inner canthus after administering the drops can potentially introduce contaminants into the eye.

Correct Answer: D

Rationale:
Correct
Answer: D


Rationale: Informed consent requires the provider to explain the risks, benefits, and alternatives of a procedure to the patient before obtaining consent. By choosing option D, the patient is informed and can make an educated decision. This promotes patient autonomy and ensures they understand the implications of the surgery.

Incorrect

Choices:
A: Informed consent is specific to the procedure being performed, not all routine treatments.
B: While a witness may be required for some procedures, it is not a universal requirement for informed consent.
C: Verbal consent may be acceptable in some cases, but for surgery, written informed consent is typically required.
E, F, G: No information is provided, making these choices irrelevant.

Correct Answer: B

Rationale: The correct answer is B: Secure the tubing with adhesive tape to the lower abdomen. This is important to prevent tension on the catheter and minimize the risk of dislodgement or kinking. Option A is incorrect because collecting a sterile specimen from the drainage bag is not appropriate as it may lead to contamination. Option C is incorrect as the client should not hold the drainage bag at waist height as it can cause backflow of urine. Option D is incorrect as coiling the tubing on the bed above the collection bag can lead to urine reflux into the bladder.

Correct Answer: C

Rationale: The correct answer is C: Clean the teeth with a small, soft-bristled toothbrush. For a 12-month-old toddler, a small, soft-bristled toothbrush is recommended as it is gentle on their delicate gums and teeth. Hard bristles could cause damage. Using a small toothbrush allows for better control and maneuverability in the child's small mouth. This helps ensure thorough cleaning without causing discomfort or injury. Positioning the bristles at a 90-degree angle (option
A) might be too advanced for a toddler. Using a 5-inch strip of toothpaste (option
B) could lead to excessive ingestion of fluoride. Flossing before brushing (option
D) may not be suitable for a toddler's teeth and gums.