The nurse is caring for a patient who becomes agitated when visitors stay for extended periods or the hospital unit becomes noisy. The nurse identifies this as sensory overload. Which interventions will be of benefit to the patient? (Select all that apply.)

Choice A reason: This is an incorrect choice because soaking the crusted areas of tape with adhesive remover is not the best approach to change nasogastric tube tape that has become crusted with secretions. Adhesive remover is a solvent that can dissolve the glue that holds the tape to the skin. However, it can also irritate the skin and cause redness, burning, or allergic reactions. The nurse should avoid using adhesive remover on the patient's face, especially near the eyes, nose, or mouth.

Choice B reason: This is an incorrect choice because saturating the tape with a denatured alcohol solution is not the best approach to change nasogastric tube tape that has become crusted with secretions. Denatured alcohol is a mixture of ethanol and other chemicals that can dissolve the glue that holds the tape to the skin. However, it can also dry out the skin and cause cracking, peeling, or bleeding. The nurse should avoid using denatured alcohol on the patient's face, especially near the eyes, nose, or mouth.

Choice C reason: This is an incorrect choice because using blunt-edged scissors to loosen the tape from the skin is not the best approach to change nasogastric tube tape that has become crusted with secretions. Blunt-edged scissors are scissors that have rounded tips instead of sharp points. They can be used to cut the tape without injuring the skin. However, they can also pull or tug on the skin and cause pain, discomfort, or damage. The nurse should avoid using scissors on the patient's face, especially near the eyes, nose, or mouth.

Choice D reason: This is the correct choice because softening the secretions using a warm moist washcloth is the best approach to change nasogastric tube tape that has become crusted with secretions. A warm moist washcloth is a cloth that is soaked in warm water and wrung out. It can be applied gently to the crusted areas of tape to soften the secretions and loosen the tape from the skin. It can also soothe the skin and prevent irritation or infection. The nurse should use a clean washcloth for each application and discard it after use.

Choice A reason: This is the correct choice because the apical pulse is the most accurate measurement of the heart rate and rhythm. Digoxin is a cardiac medication that affects the heart rate and can cause arrhythmias. Therefore, the nurse should use the apical pulse to monitor the patient's response to the medication.

Choice B reason: This is an incorrect choice because the carotid pulse is not the best site to measure the heart rate before administering digoxin. The carotid pulse is located in the neck and can be affected by external factors such as pressure or movement. The carotid pulse is also not recommended for routine use because it can stimulate the vagus nerve and lower the heart rate.

Choice C reason: This is an incorrect choice because the radial pulse is not the best site to measure the heart rate before administering digoxin. The radial pulse is located in the wrist and can be affected by peripheral factors such as circulation or temperature. The radial pulse can also be inaccurate or irregular if the patient has an arrhythmia.

Choice D reason: This is an incorrect choice because the brachial pulse is not the best site to measure the heart rate before administering digoxin. The brachial pulse is located in the upper arm and can be affected by arm position or blood pressure. The brachial pulse is also not as reliable as the apical pulse for detecting changes in the heart rate and rhythm.