Pharmacology and the Nursing Process 10th Edition Test Bank

Correct Answer: A

Rationale: The correct answer is A: Deficient fluid volume related to osmotic diuresis. With a serum glucose level of 618mg/dl, the client is likely experiencing diabetic ketoacidosis, leading to excessive urination (osmotic diuresis) and dehydration. The priority is to address fluid volume deficit to prevent hypovolemic shock. The other options are not the priority because: B: Decreased cardiac output is a result of the increased heart rate, not the primary issue. C: Imbalanced nutrition is important but not as urgent as fluid volume deficit. D: Ineffective thermoregulation is a concern but not the priority in this scenario.

Correct Answer: B

Rationale: The correct answer is B because turning the patient every 2 hours helps prevent pressure ulcers caused by shearing forces. This intervention redistributes pressure, improving blood flow to the skin, thus reducing the risk of skin breakdown. Administering pain medication (A) does not directly address the skin integrity issue. Monitoring vital signs (C) is important but does not address skin integrity. Keeping bed rails up (D) may actually increase the risk of shearing forces.

Correct Answer: B

Rationale: The correct answer is B because starting birth control pills does not protect against HIV transmission to the baby during pregnancy. The other choices demonstrate understanding of HIV transmission risks and prevention methods. A shows awareness of vertical transmission, C recognizes that not all babies born to HIV-positive mothers are infected, and D acknowledges the potential need for a C-section to reduce transmission risk. Starting birth control pills is unrelated to preventing mother-to-child HIV transmission during pregnancy.

Correct Answer: A

Rationale: Step-by-step rationale: 1. The nurse should clarify discrepancies of assessment data with the client to ensure accurate information. 2. The client's denial of breathing problems conflicts with physical signs, indicating a potential lack of awareness or reluctance to disclose symptoms. 3. By clarifying with the client, the nurse can address any misunderstandings or encourage honest communication. 4. This approach promotes client-centered care and ensures a comprehensive understanding of the client's health status. Summary: - Choice A is correct as it addresses the need to clarify discrepancies with the client for accurate assessment. - Choice B is incorrect as validation with the healthcare team may not provide insight into the client's perception. - Choice C is incorrect as it does not address the need to resolve conflicting assessment data. - Choice D is incorrect as family input may not provide accurate information if the client denies symptoms.

Correct Answer: B

Rationale: Correct Answer: B: Calcium should be avoided Rationale: 1. Calcium is an essential mineral for bone health, especially important for individuals with limited mobility like Richard. 2. Avoiding calcium can lead to bone weakening and increase the risk of fractures. 3. Nursing care plans should include adequate calcium intake to support bone health. 4. Therefore, avoiding calcium is not a recommended nutritional consideration. Summary of Incorrect Choices: A: The diet should be semisolid to facilitate the passage of food - This is important for individuals with swallowing difficulties. C: The patient should be sitting in an upright position during feeding - This aids in proper digestion and reduces the risk of aspiration. D: Thick fluids should be encouraged to provide additional calories - Thick fluids may increase the risk of aspiration in patients with neurological conditions.