The correct Answer: 4 side rails pulled up by the nurse. Do not allow 4 side rails up even if the patient is on or off restraint.

The correct answer is: Failure to perform an important nursing responsibility is a form of negligence. Choice B does not constitute negligence. Digoxin is not administered if apical rate is 60bpm and below to prevent bradycardia. Choice C is a correct nursing action. It does not constitute negligence. Choice D is also a correct action. Potassium is not given if urine output is not adequate (urine output should be at least 30mls/hour).

The correct answer is: Rolling from front to back is a common behavior of a 6 month old baby also a dangerous time for the baby to fall when left alone in the bed.

The correct answer is: 1. eye opening 2. motor response 3. verbal performance. The Glasgow coma scale is a clinical scale used to reliability measure a person's level of consciousness after a brain injury.

The correct answer is: Cover the ulcer with transparent dressing. Radiation therapy may cause desquamation of skin in the areas involved. The client should avoid applying lotion, powder or heat and cold application in the area. There is no need for isolation after external radiation therapy.

The correct answer is: Increased urine output after transphenoidal surgery may indicate occurrence of diabetes insipidus. This is supported by low specific gravity of urine. Choices C and D are expected manifestations after this type of surgery. CSF leakage from the nose is normal for 72 hours postoperative. The incision is done between the upper lip and upper gum.

The correct answer is: Discussing a patient’s condition outside the nursing unit, like in cafeteria, elevator and parking lot consists invasion of privacy. Always remember only the patient can tell anyone about their conditions but when the patient becomes incapacitated the healthcare agent is allowed to provide and receive patient information's.

The correct answer is: Cannot be given with regular insulin. The long acting insulin cannot be combined with regular insulin.

The correct answer is: A full liquid diet is made up only of fluids and foods that are normally liquid and foods that turn to liquid when they are at room temperature, like ice cream. It also includes strained creamy soups, tea, juice, Jell-O, milkshakes, pudding, and popsicles.

The correct answer is: Antidepressants start to take effect at a minimum of after a week. Full therapeutic effect will be evident in 3 to 4 weeks. Zoloft, an SSRI does not require special diet. MAOI should not be taken with tyramine- rich foods to prevent hypertensive crisis. Antidepressants may cause elevation of blood pressure, not hypotension.

The correct answer is: Foot care is necessary in clients with DM to prevent gangrene formation. Choice D is incorrect. Cutting lateral edges of the toenails and removing ingrown may cause trauma that may lead to gangrene. Choice D is incorrect. Cutting lateral edges of the toenails and removing ingrown may cause trauma that may lead to gangrene. Choice E is incorrect. Lotion, cream, powder should not be applied in spaces between the toes. These may cake and cause infection.

The correct answer is: Left homonymous hemianopsia, Right sided weakness and uncoordinated movements are manifestations of Left CVA. Choices  C and D are manifestations of right CVA.

The correct answer is: Effective management of CHF produce the following expected outcome: increased cardiac output, increased urine output, decreased weight, lowering of BP, may include stronger pulse, normal breath sounds.

The correct answer is: Metabolic alkalosis leads to hypokalemia, hypocalcaemia and hyperphosphatemia. In alkalosis there is increased excretion of potassium, calcium is damaged. As calcium decreases, there is inverse hyperphosphatemia.

The correct answer is: To stop the burning process, the body part with burns should be immersed in cold water. Jewelries should be removed because metals can be superhead and will cause further tissue injury. Applying dressings on the fingers separately prevents contractures and adhesions. Splints should be applied with the fingers curbed to allow flexion and extension exercises of the fingers. This will also prevent hyperextension deformity of the fingers.

The correct answer is: Dehydration is characterized by elevated body temperature, tachycardia, tachypnea due to sympathetic nervous stimulation. Decreased urine output, dark concentrated urine and weight loss also occur. Fluid loss from the body will result to hypotension due to decrease in circulating volume.

The correct answer is: Hypothyroidism is characterized by hypometabolism, decreased body heat production and hypercalcemia (“Everything is low, slow and dry.”). Choices A, B and C are manifestations of hyperthyroidism.

The correct answer is: The emergent phase of burns is also called shock phase or fluid accumulation phase. This occurs during the first 48 hours of burns. The fluid shifting is fromIVC to ISC due to vasodilation. This results from the heat and release of histamine in response to tissue injury.

The correct answer is: Second degree burns affect the epidermis and dermis; the area appears reddish, moist, with blisters or vesicles, it is painful, it is partial thickness burns.

The correct answer is: Choice C is incorrect. Beta- blockers like Atenolol should be given on full stomach to prevent GI irritation.