Test Bank Pharmacology and the Nursing Process

Correct Answer: C

Rationale: The correct answer is C: platelets 18,000. A critically low platelet count can lead to life-threatening bleeding in the ICU. Normal platelet count ranges from 150,000 to 450,000. A count of 18,000 indicates severe thrombocytopenia. Immediate reporting is crucial for prompt intervention. Rationale for why other choices are incorrect: A: Hematocrit of 48% is within normal range (male: 42-52%, female: 37-47%). B: paCO2 of 38 mm Hg is within normal range (35-45 mm Hg). D: WBC count of 8000 is within normal range (4000-11000/uL). In critical care settings, it is vital to prioritize and address life-threatening conditions promptly, hence the urgent need to report the critically low platelet count.

Correct Answer: D

Rationale: The correct answer is D: Suggest referral to a sex counselor or other appropriate professional. This is the most appropriate intervention as it addresses the client's concern about impotence affecting his marriage by offering specialized help from a professional who can provide counseling and guidance on managing sexual issues related to diabetes. Referring the client to a sex counselor ensures that he receives expert support in addressing his specific concerns and helps improve his overall well-being and quality of life. A: Encouraging the client to ask questions about personality sexuality may not address the underlying issue of impotence and its impact on the marriage. B: Providing time for privacy is important but may not directly address the client's concerns about impotence. C: Providing support for the spouse or significant other is beneficial, but the primary focus should be on addressing the client's specific concerns about impotence.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates data validation in making a nursing clinical decision. The nurse assesses the time of the last dressing change and compares it with the appearance of old and new drainage. This process ensures that the decision to remove the wound dressing is based on accurate and validated data, leading to appropriate patient care. Choice B is incorrect because it does not involve data validation. The decision is driven by increased pain and family requests, without verifying the underlying cause. Choice C is incorrect as it involves responding to a patient's reported symptom (leg cramps), but it does not involve data validation in making the clinical decision. Choice D is incorrect as it relies solely on the patient's report of decreased mobility without further data validation.

Correct Answer: C

Rationale: The correct answer is C: platelets 18,000. A critically low platelet count can lead to life-threatening bleeding in the ICU. Normal platelet count ranges from 150,000 to 450,000. A count of 18,000 indicates severe thrombocytopenia. Immediate reporting is crucial for prompt intervention. Rationale for why other choices are incorrect: A: Hematocrit of 48% is within normal range (male: 42-52%, female: 37-47%). B: paCO2 of 38 mm Hg is within normal range (35-45 mm Hg). D: WBC count of 8000 is within normal range (4000-11000/uL). In critical care settings, it is vital to prioritize and address life-threatening conditions promptly, hence the urgent need to report the critically low platelet count.

Correct Answer: C

Rationale: The correct answer is C: Staying at patient's bedside. This is the most helpful nursing action because it provides reassurance and support to the anxious patient experiencing dyspnea. By staying at the bedside, the nurse can monitor the patient closely, provide immediate assistance if needed, and offer a calming presence. Explanation of why other choices are incorrect: A: Increasing activity levels may worsen the dyspnea and anxiety of the patient. B: Pulling the privacy curtain does not directly address the patient's anxiety or dyspnea. D: Closing the patient's door may make the patient feel isolated and increase anxiety. In summary, staying at the patient's bedside is the most effective nursing action as it addresses both the physical and emotional needs of the anxious patient with dyspnea.