For the correct answer choice:
Inquiring about recent changes in the client's environment can provide insight into factors contributing to wandering, helping to formulate a plan for safety.

For incorrect answer choices:
It might be best to consider a more supportive living arrangement is incorrect. This suggestion does not consider potential home-based solutions and could be alarming for the family.

This is a known pattern often seen in individuals with dementia is incorrect. While accurate, this response does not help address the family's current concerns or guide them toward a solution.

Be prepared; his symptoms will likely become more challenging to manage is incorrect. This statement is pessimistic and does not provide helpful information or reassurance.

For the correct answer choice:
Encouraging the client to keep the arm elevated when resting is effective in safeguarding the fistula. Elevation can help reduce swelling and maintain proper blood flow.

For incorrect answer choices:
Placing a restriction sign on the client's IV pole is incorrect. Although visible reminders are beneficial, they do not actively prevent injury to the fistula.

Informing the healthcare team members about the fistula's location is incorrect. While communication is important, it does not directly prevent potential harm to the fistula.

Ensuring the client's health record is updated with the fistula information is incorrect. While documentation is essential, it does not actively contribute to protecting the fistula.

For correct answer choice:
Candidiasis is correct. The presence of a white coating on the oral mucosa, along with difficulty swallowing, suggests a fungal infection, common in immunocompromised clients such as those receiving chemotherapy.

For incorrect answer choices:
Oral leukoplakia is incorrect. This condition usually presents as thick, white patches that are often painless and not associated with swallowing difficulties, making it less likely in this scenario.

Oral lichen planus is incorrect. While it may cause white lesions, they typically appear as lacy patches rather than a coating and are not specifically linked to chemotherapy.

Viral pharyngitis is incorrect. This condition can cause throat discomfort but would not typically present with white lesions in the mouth, making it an unlikely cause for the symptoms described.

For correct answer choice:
Banana is correct. Due to its potential to cause allergic reactions in those with latex allergies, bananas should be avoided in their diet.

For incorrect answer choices:
Broccoli is incorrect. This vegetable does not contain any latex proteins and is safe for consumption by a client with a latex allergy.

Pasta is incorrect. As a carbohydrate food, pasta does not carry latex proteins and is safe for this client.

Yogurt is incorrect. This dairy product does not pose a risk for those with latex allergies and can be included in their diet.

For correct answer choice:
Explaining the medication's purpose to the child is correct. This helps the child understand what they are taking and can reduce anxiety or resistance during administration.

For incorrect answer choices:
Asking the child if they remember the last dose is incorrect. This might confuse the child and does not provide relevant information for the nurse regarding current medication administration.

Requesting the child's sibling to help with the medication is incorrect. This may not be appropriate as it could lead to misunderstanding and does not ensure safe administration practices.

Reviewing the child's health history before administration is incorrect. While important, it should be done prior to medication preparation and not immediately before administration.

For correct answer choice:
Calling the pharmacy to verify the medication before administering is correct. This ensures that the nurse administers the correct medication, preventing potential errors.

For incorrect answer choices:
Administering the medication and monitoring the client for side effects is incorrect. Administering an uncertain medication is unsafe; verification is necessary.

Asking the charge nurse to review the medication's appearance is incorrect. While another nurse may help confirm suspicions, the pharmacy has the most accurate information about medications.

Reordering the medication from the pharmacy is incorrect. Verification of the existing medication should be done first to confirm its accuracy.

For the correct answer choice:
Notifying supervisors immediately following any potential HIV exposure is of utmost importance. Prompt action ensures that necessary measures are taken to address the risk.

For incorrect answer choices:

Early treatment after exposure can include the use of antiretroviral medications is incorrect. While treatment is vital, it is not as immediate as the need to report the exposure itself.

The risk of HIV transmission from clients to healthcare workers is considered minimal is incorrect. This statement may mislead staff regarding the seriousness of exposure incidents, highlighting the need for immediate action.

Specific intervals must be adhered to for HIV testing after potential exposure is incorrect.

For the correct answer choice:
Tape is essential for securing the NG tube in place and can be quickly used to reattach it if it becomes dislodged, making it vital for maintaining the tube's position.

For incorrect answer choices:
A scalpel is incorrect. This tool is not typically needed at the bedside for an NG tube client and is used for surgical procedures rather than tube management.

A needle is incorrect. While needles are used for various medical interventions, they are not necessary for managing an NG tube.

A suction catheter is incorrect. Although suction may be needed for some clients, it is only specifically required for some NG tube clients if there are complications requiring suctioning.

For the correct answer choice:
Assisting in repositioning the client every two hours is appropriate for a CNA. This task is within the CNA's scope, promoting comfort and preventing pressure ulcers.
For incorrect answer choices:
Changing the ventilator settings based on blood gas results is incorrect. This requires nursing judgment and knowledge, as it is a critical task that affects client safety.

Evaluating the effectiveness of ventilator support is incorrect. This task requires a comprehensive assessment that only a nurse can perform.

Documenting the client's sedation levels and respiratory rate is incorrect. This requires nursing assessment and decision-making skills, which are beyond a CNA's responsibilities.

For the correct answer choice:
A. Discarding the contaminated item and replacing it with new sterile supplies is essential to maintain sterility. This action prevents the risk of infection and ensures a safe dressing change.

For incorrect answer choices:
Covering the contaminated area with a sterile drape and continuing is incorrect. This does not adequately address the contamination, as the sterility of the entire field could be compromised.

Cleaning the area with an antiseptic solution before proceeding is incorrect. Cleaning does not restore the sterility of the field and is not an appropriate method to salvage a compromised sterile environment.

Informing the charge nurse and waiting for further instructions is incorrect. While it's important to communicate issues, immediate action should be taken to maintain sterility rather than delaying with further instructions.

For the correct answer choice:
Gloves should be removed first because they are the most contaminated. The full CDC-recommended sequence for removing PPE is as follows:

1. Gloves
2. Gown
3. Eye protection (e.g., goggles or face shield)
4. Mask

Gloves are removed first to prevent the spread of germs to other PPE or body parts.

For incorrect answer choices:

Gown is incorrect. The gown is removed after gloves to avoid spreading contamination from the gown to the hands.

Mask is incorrect. The mask is removed last to prevent respiratory exposure.

Eye protection is incorrect. Eye protection should be removed after gloves and gown to avoid contamination of the face.

For correct answer choice:
Nosocomial is correct. This term is used to describe infections that clients acquire while in a hospital or healthcare facility, usually as a result of exposure to pathogens present in that environment.

For incorrect answer choices:
Iatrogenic is incorrect. This term specifically refers to complications or infections that arise directly from medical interventions or treatments, not solely due to hospital-acquired conditions.

Chronic is incorrect. This term refers to infections or diseases that persist over a long duration, regardless of where they are acquired, and do not pertain to the hospital setting.

Contagious is incorrect. This term describes infections that can be transmitted from one person to another, but it does not specifically refer to infections acquired in a healthcare setting.

For the correct answer choice:
The procedure can help lower intraocular pressure effectively. Laser treatments, such as selective laser trabeculoplasty, are designed to enhance fluid drainage and reduce pressure in the eye, which is critical in managing glaucoma.

For incorrect answer choices:
It typically requires a lengthy recovery period is incorrect. Laser treatments for glaucoma usually have minimal recovery time, and clients often return to normal activities quickly.

It is a last resort if medications fail is incorrect. Laser therapy is often used as an early intervention alongside medication.

Most clients experience significant pain during the procedure is incorrect. Laser treatment is typically well-tolerated, and significant pain is not a common experience for clients.

For the correct answer choice:
Performing regular audits of hand hygiene compliance is critical as it directly addresses one of the most effective ways to prevent the spread of infections, including C. difficile.

For incorrect answer choices:
Advising clients to wear masks when in common areas is incorrect. Masks are not effective in preventing the spread of C. difficile, which is primarily transmitted via the fecal-oral route.

Encouraging clients to refrain from using shared restrooms is incorrect. While limiting shared restroom use may help, it does not address the core issue of infection prevention.

Distributing educational pamphlets about C. difficile to clients and families is incorrect. While education is important, it does not have the immediate impact on infection control that auditing hand hygiene does.

For the correct answer choice:
Assembling a team to manage triage is crucial as it allows for effective prioritization of care based on client needs. Triage is essential in mass casualty incidents to ensure that those with the most urgent needs receive immediate attention.
For incorrect answer choices:
Reviewing client charts for discharges is incorrect. While discharges may help, the priority should be to establish a triage system to handle the incoming clients effectively.

Calling for additional staff is incorrect. Although staffing may be necessary, the first action should focus on triaging clients to direct care where it is most needed.

Ensuring supplies and equipment are ready is incorrect. While this is important, the immediate need in a disaster is to establish a triage system to manage client flow efficiently.

For the correct answer choice:
Following standard infection control measures consistently is the best practice to prevent infections. This includes hand hygiene and using appropriate personal protective equipment as needed, regardless of the client's diagnosis.

For incorrect answer choices:
Encouraging the use of a walking aid during ambulation is incorrect. While it is important for mobility, it does not directly prevent infection.

Ensuring the client wears a mask while eating is incorrect. This action may be unnecessary unless the client is at high risk of respiratory infections, but it does not address overall infection prevention.

Providing hand hygiene supplies at the bedside is incorrect. While hand hygiene is critical, it is only part of a broader infection control strategy that must be consistently applied.

For correct answer choice:
Rescue clients in immediate danger is correct. According to the RACE protocol, the first action is to rescue those who are at risk before activating the alarm or taking other steps.

For incorrect answer choices:
Pull the fire alarm to alert others is incorrect. While activating the alarm is crucial, the first priority is ensuring clients' safety in immediate danger.

Contain the fire by closing doors is incorrect. Containment is part of the protocol but comes after ensuring that all clients in danger are rescued.

Evacuate clients from the building is incorrect. Although evacuation is necessary, it is not the first step; the safety of those in immediate danger must be addressed first.

For correct answer choice:
Apply a gait belt to maintain secure support is correct. The gait belt is essential for providing the nurse with a way to assist the client closely and securely, helping to prevent any falls during their first walk.

For incorrect answer choices:
Provide the client with a walker to enhance stability is incorrect. Although a walker is a good mobility aid, it does not allow for direct assistance from the nurse, which is critical for safety after cardiac surgery.

Recommend the use of crutches to aid mobility is incorrect. Crutches are not suitable for clients who may lack the necessary strength and coordination, especially immediately following surgery.

Offer a cane for the client to use as support is incorrect. A cane requires balance and is less stable than a gait belt, making it inappropriate for a client recovering from cardiac surgery.

For the correct answer choice:
Regular assessments of skin integrity help identify any early signs of infection, especially in clients who may have limited mobility or compromised health following a stroke.

For incorrect answer choices:
While using barrier precautions is important, assessments provide ongoing monitoring and prevention of infection.

Masks may not be necessary unless the client has specific respiratory needs or conditions; family members should follow general infection prevention practices.

Although sanitizing equipment is essential, proactive skin assessments can lead to earlier intervention in preventing infections.

For the correct answer choice:
Notifying the physician and completing an incident report is essential following a medication error. This ensures that appropriate interventions can be taken and facility policies formally document the error.

For incorrect answer choices:
Documenting the error in the client's chart without further action is incorrect. While documentation is necessary, immediate physician notification is crucial for client safety and proper management of the error.

Monitoring the client for adverse effects is incorrect. Although monitoring is essential, the first step after recognizing a medication error should be to notify the physician and take action as directed.

Reassuring the client that no harm will come from the error is incorrect. This could lead to misinformation; the nurse must follow up with the physician to evaluate the potential impacts of the error.