Correct Answer: D

Rationale: The correct answer is D: "I will place the client in a private room." This is correct because MRSA is highly contagious, and placing the client in a private room helps prevent the spread of infection to other clients. Placing the client in a private room also helps to protect healthcare workers and visitors from exposure.

A: "I will remove the gown before my gloves after providing client care." This is incorrect because the proper sequence is to remove gloves first, followed by the gown to prevent contamination.

B: "I will tell the client's visitors to wear a mask when they are within 3 feet of the client." This is incorrect because visitors may not need to wear a mask unless they are providing direct care to the client.

C: "I will wear an N95 respirator mask when caring for the client." This is incorrect because an N95 respirator mask is not typically required for caring for a client with MRSA unless performing aerosol-generating procedures.

Overall, placing

Correct Answer: C

Rationale: The correct answer is C: Place the extremity in a dependent position. Placing the extremity in a dependent position facilitates venous distention, making it easier to locate and access the vein for IV insertion. This position helps increase blood flow to the area and allows gravity to assist in dilating the veins. Placing the tourniquet below the proposed insertion site (
A) would impede venous return and make it difficult to visualize and access the vein. Applying a cool compress (
B) would cause vasoconstriction and make the veins less visible and accessible. Choosing the most proximal site on the extremity (
D) may not be necessary and could increase the risk of complications such as infiltration or phlebitis.

Correct Answer: D

Rationale:
Rationale: The correct answer is D because delirium typically has an abrupt onset, manifesting as a sudden change in mental status. This is crucial for nurses to recognize promptly for appropriate intervention.
Choice A is incorrect as delirium can disrupt a client's sleep cycle.
Choice B is incorrect as delirium can alter a client's perception of their environment.
Choice C is incorrect as delirium often has a rapid progression, not a slow one.
Therefore, choice D is the most appropriate statement to include in the educational program.

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.