Correct Answer: A

Rationale: Soap and water effectively clean the perineum, maintaining hygiene. Using one washcloth section risks contamination, air drying causes irritation, and cleaning from rectum to perineum spreads bacteria.

Correct Answer: B

Rationale: Assessing circulation and neurological integrity every 2 hours prevents restraint-related injuries. Square knots are hard to release, side rails risk entrapment, and 12-hour checks are too infrequent.

Correct Answer: A

Rationale: Financial difficulties cause mental and emotional stress, a psychological stressor. Hypothermia, burns, and fractures are physiological stressors affecting physical health.

Correct Answer: B

Rationale: Observing the client check their pulse assesses psychomotor skills (physical performance). Reviewing steps, discussing purpose, and sharing ranges are cognitive learning methods.

Correct Answer: B

Rationale: Repositioning every 2 hours is an independent nursing action within the nurse’s scope to prevent pressure ulcers, requiring no provider order. Administering medications or starting IV antibiotics are dependent interventions, needing a physician’s prescription.