The nurse is a first responder following a multi-vehicle accident and performs triage on the victims while waiting for further assistance. A person walks up to the nurse with a minor head wound and asks to be treated. Which response by the nurse is appropriate?

The patient who is scheduled for an elective surgery in 2 hours asks the nurse, “What time do the maids typically come to clean the hotel room?” Further questioning reveals the patient believes the hospital in the United States is a hotel in Paris, France, and the year is 20 years prior. The nurse notes that the patient signed a consent form for the procedure just minutes ago. Which action does the nurse take first?

The nurse is supervising the care of the patient who suffered an embolic stroke of the right middle cerebral artery after a clot formed on the patient’s prosthetic mitral valve. Which instruction does the nurse provide to the unlicensed assistive personnel that will be most important to prevent bacterial endocarditis?