Pharmacology and the Nursing Process 10th Edition Test Bank Quizlet

Correct Answer: A

Rationale: The correct answer is A: Maintain strict records of intake and output. This is the best way to assess fluid balance in a burn patient because it provides quantitative data on fluid intake and output, helping to monitor for fluid imbalance. Monitoring skin turgor (B) is unreliable in burn patients due to skin damage. Weighing the client daily (C) may not accurately reflect fluid balance changes. Checking for edema (D) is not specific to assessing fluid balance in burn patients. Maintaining intake and output records allows for precise monitoring and early detection of fluid shifts, making it the most appropriate choice.

Correct Answer: A

Rationale: The correct answer is A: Obtain his oral temperature. Seizure precautions typically include avoiding putting objects in the mouth to prevent injury during a seizure. Taking an oral temperature involves placing an object in the mouth, which could pose a risk if a seizure occurs. Choices B, C, and D are not contraindicated as they do not directly involve potential risks during a seizure. Allowing the patient to wear his own clothing, encouraging personal hygiene, and promoting mobility are safe practices that do not increase the risk of harm during a seizure.

Correct Answer: A

Rationale: The correct answer is A because it addresses the specific nursing interventions needed for a patient with head injuries like J.E. Skin care and repositioning every 2 hours help prevent pressure ulcers. Maintaining extremity alignment prevents contractures. Respiratory exercises aid in lung expansion and prevent complications. The other choices are incorrect because they either lack essential interventions (B) or include unnecessary or inappropriate interventions (C, D). Teaching the use of an overhead trapeze is not necessary for head injuries, and intermittent positive pressure breathing therapy may not be indicated. Choice A provides a comprehensive and targeted approach to address the specific needs of a patient with head injuries.

Correct Answer: C

Rationale: Step 1: Reading labels carefully on vials containing flush solutions for locks is crucial to ensure the correct solution is being used. Step 2: Potassium chloride should not be used to flush locks as it can be fatal if administered incorrectly. Step 3: By carefully reading labels, the nurse can verify that the correct solution is being used, thus minimizing the risk of using potassium chloride. Summary: - Choice A is incorrect as using a dilute form of potassium chloride does not address the issue of incorrect administration. - Choice B is incorrect as warming the solution does not prevent the risk associated with using potassium chloride. - Choice D is incorrect as replacing locks does not address the root cause of the issue, which is improper administration.

Correct Answer: A

Rationale: The correct answer is A because after a total thyroidectomy, the client will no longer produce thyroid hormones, necessitating lifelong replacement therapy. This statement shows an understanding of the need for ongoing medication to maintain thyroid function. Choice B is incorrect as the client had a total thyroidectomy, so there is no risk of hyperthyroidism recurrence. Choice C is incorrect as the client will need ongoing care and monitoring for thyroid function. Choice D is incorrect as increasing caloric intake is not a necessary long-term care measure after a thyroidectomy.