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: C

Rationale: The correct answer is C: Observe wound appearance and edges. This is the first intervention the nurse should perform because assessing the wound's appearance and edges provides crucial information about the healing process and any signs of infection. It helps in determining the next steps in the care plan. Reinforcing the dressing (A) and performing dressing changes (B) should come after assessing the wound. Documenting wound characteristics (D) is important but should also follow the initial assessment.

Correct Answer: C

Rationale: The correct answer is C: An intravenous set-up. Checking for an intravenous set-up is crucial to ensure that Mrs. Zeno is receiving necessary medications or fluids. It allows the nurse to monitor the infusion rate, prevent potential complications like infiltration, and ensure proper medication administration. A tracheostomy set (A) may be important for respiratory support but not essential for immediate safety. A hypothermia blanket (B) is used for temperature management and not directly related to Mrs. Zeno's immediate safety. A syringe and edrophonium HCl (D) are specific to a diagnostic test for myasthenia gravis and not necessary for general bedside safety assessment.

Correct Answer: D

Rationale: The correct answer is D: Exhale deeply as the nurse re-inflates the cuff. Rationale: 1. When the cuff of the tracheostomy tube is deflated, the client should be instructed to exhale deeply to prevent aspiration of secretions. 2. Exhaling helps to clear the airway by pushing secretions out of the trachea, reducing the risk of aspiration. 3. Inhaling or holding the breath while the cuff is being re-inflated can increase the risk of inhaling secretions. 4. Coughing as the cuff is being deflated (choice A) may not be as effective in clearing secretions as exhaling deeply. 5. Taking a deep breath as the nurse deflates the cuff (choice C) may not be as effective as exhaling deeply in preventing aspiration. In summary, choice D is the correct answer because exhaling deeply helps clear secretions and reduce the risk of aspiration, while the other choices may

Correct Answer: C

Rationale: The correct answer is C: Use the smallest needle possible for injections. In a client with thrombocytopenia (low platelet count), there is an increased risk of bleeding and bruising. Using the smallest needle possible for injections reduces the risk of causing injury to blood vessels and tissues, minimizing bleeding complications. Limiting visits by family members (choice A) is not directly related to protecting the client's safety. Encouraging wheelchair use (choice B) is not necessary unless indicated for mobility reasons. Maintaining accurate fluid intake and output records (choice D) is important for overall client care but does not directly address the risk of bleeding in thrombocytopenia.