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A decreased sense of balance is a normal age-related change that occurs in older adults due to changes in the vestibular system, vision, and proprioception. Nighttime urinary incontinence, increased nighttime sleeping, and heightened sense of pain are not normal findings and may indicate underlying health problems.

The nurse can delegate tasks that are routine, unskilled, and do not require nursing judgment to assistive personnel. Assisting the client to select food choices from the menu is an example of such a task. Evaluating the client's response to pain medication, monitoring the characteristics of the client's chest tube drainage, and teaching deepbreathing and coughing to the client are tasks that require nursing judgment and skill and should not be delegated.

When caring for a client who has restraints, the nurse should follow the ABCDE priority-setting framework and assess airway, breathing, circulation, disability, and exposure first. Peripheral pulses are an indicator of circulation and should be assessed first to ensure adequate blood flow to the extremities. Comfort level, skin integrity, and elimination needs are also important assessments but are not as high priority as circulation.

The nurse should explain the need to have another adult drive the client home following surgery, as this is a safety measure to prevent complications such as bleeding, infection, or injury due to impaired cognition or mobility after anesthesia or sedation. The nurse should ask the client to shower once with an antiseptic soap on either the night before or morning of surgery, not 3 times the day before surgery, as this can reduce the risk of surgical site infection. The nurse should inform the client that they cannot wear makeup during surgery, as this can interfere with the monitoring of skin color and oxygen saturation. The nurse should instruct the client to stop drinking clear liquids at least 2 hours before surgery, not 1 hour before surgery, as this can reduce the risk of aspiration and gastric distension.

D. "I will place the suppository as far inside my vagina as I can reach.”: This statement is correct. The suppository should be inserted high into the vagina to ensure it is placed correctly and will dissolve properly to treat the infection.

A nurse should use an interpreter who speaks the client's language when providing discharge instructions to ensure effective communication and understanding of the information. The interpreter should be a trained professional who can convey the message accurately and respect confidentiality.

The nurse should ask a second nurse to record her signature when wasting any unused portion of the controlled substance. This is to ensure accountability and prevent diversion of narcotics. The nurse and the witness should document the amount wasted and the reason for wasting in the log book or electronic system.

A nursing incident report is a document that provides detailed information and account of the chain of events leading up to and following an unforeseen circumstance in a healthcare setting or facility especially in the nursing side. An incident report is used to communicate important safety information to hospital administrators and keep them updated on aspects of patient care for risk management, quality assurance, educational, and legal purposes. An incident report should be completed within 24 hours by whomever witnessed the incident or was notified first. In this case, the nurse should complete an incident report because the visitor's fall is an unforeseen circumstance that threatens patient safety and could have legal implications.

This is because crackles are a sign of fluid overload in the lungs, which can occur when a client receives too much IV fluid. Fluid overload can cause pulmonary edema, which is a life threatening condition that reduces oxygen exchange in the lungs. Some other signs and symptoms of fluid overload include rapid weight gain, swelling in the arms, legs and face, high blood pressure and shortness of breath.