A nurse has developed a plan of care with nursing interventions designed to meet specific client outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation?

Correct Answer: B

Rationale: The correct answer is B: Make recommendations for revising the plan of care. When client outcomes are not met within the specified time frame, the nurse should reassess the plan of care to identify any potential reasons for the lack of progress. By making recommendations for revising the plan of care, the nurse can adjust interventions to better align with the client's needs and facilitate goal achievement. Continuing to follow the written plan of care (choice A) without modification may not address the underlying issues preventing goal attainment. Asking another health care professional to design a plan of care (choice C) may not be necessary if the nurse can assess and revise the current plan. Stating 'goal will be met at a later date' (choice D) does not address the need for immediate action to reassess and modify the plan for better outcomes.

Correct Answer: C

Rationale: The correct answer is C: An inference. When the nurse documents that the client is confused, it is an interpretation or conclusion drawn from the observed behavior or symptoms. Inferences are based on subjective and objective data. Subjective data (choice A) is based on what the client states, while a data cue (choice B) is a piece of information that may lead to an inference but is not the actual interpretation. Primary data (choice D) refers to firsthand information obtained directly from the client, which is not the case here. In this scenario, the nurse is making an inference based on the observed confusion, making choice C the correct answer.

Correct Answer: B

Rationale: The correct answer is B: Do not stop medication abruptly. Abruptly stopping propranolol can lead to rebound hypertension and potentially life-threatening complications. The nurse should emphasize the importance of gradual tapering under medical supervision to avoid adverse effects. A: Having potassium levels checked is not directly related to propranolol use for hypertension management. C: Changes in appetite are not specific to propranolol use and may not be a significant concern compared to abrupt cessation of the medication. D: Resuming usual daily activities is important but not as crucial as the correct instruction to avoid abrupt discontinuation of propranolol.

Correct Answer: D

Rationale: The correct answer is D: 4, 5, 2006. Upon admission, a patient with allergies to bee stings may exhibit tachycardia (increased heart rate) due to an allergic reaction. Respiratory stridor (high-pitched wheezing) may occur as a sign of airway inflammation. Retinal hemorrhage and dyspnea (difficulty breathing) are not typically associated with bee sting allergies. Pallor and numbness/tingling are also not common symptoms in this scenario. Therefore, choices A, B, and C are incorrect.

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: B

Rationale: The correct answer is B: prothrombin time. In liver cirrhosis, the liver's ability to produce clotting factors is impaired, leading to prolonged prothrombin time. This indicates an increased risk of bleeding. Choice A is incorrect as carbon dioxide levels are not typically affected by liver cirrhosis. Choice C, gastric pH, is unrelated to liver function. Choice D, white blood cell count, is not directly affected by liver cirrhosis. Therefore, the alteration in prothrombin time is the most relevant laboratory value to monitor in this case.

Correct Answer: C

Rationale: The correct initial action for the nurse is to ask the patient about the facial grimacing with movement (Choice C). This is important because the patient may not accurately express their pain level verbally. By addressing the discrepancy between the patient's verbal report and non-verbal cues, the nurse can gather more information to assess the patient's pain accurately. By directly communicating with the patient, the nurse can ensure that the appropriate interventions are provided. Choice A is incorrect because it disregards the need to address the patient's pain assessment. Choice B assumes the patient's preference without further clarification. Choice D jumps to administering pain medication without fully assessing the situation, which could lead to inappropriate treatment.

Correct Answer: D

Rationale: The correct answer is D: “You must avoid hyperextending your neck after surgery.” This is because hyperextending the neck can put strain on the surgical incision site and increase the risk of complications. A: Incorrect, as the head of the bed should be elevated to reduce swelling and promote drainage. B: Incorrect, as deep breathing and coughing are important to prevent pneumonia and promote lung expansion. C: Incorrect, as swallowing may be difficult initially but should improve gradually.

Correct Answer: B

Rationale: The correct answer is B because maintaining the head of the bed at a 30-degree angle can cause the radioactive material to shift within the client's body, increasing the risk of radiation exposure. This position should be avoided to prevent displacement of the applicator. A: Strict bed rest is appropriate to minimize movement and dislodgement of the applicator, ensuring proper treatment delivery. C: Providing a bed bath does not pose a radiation hazard as long as proper precautions are taken. D: Checking the applicator's position every 4 hours is essential for monitoring and ensuring it remains in place to deliver the intended treatment.