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: D

Rationale: The correct answer is D because the nurse's signature indicates that they verified the patient's signature on the consent form. This step ensures that the patient has signed the document willingly. Choice A is incorrect because the nurse doesn't obtain informed consent, that's the responsibility of the physician. Choice B is incorrect because nurses do not provide informed consent. Choice C is incorrect as the nurse witnessing the signature doesn't imply they answered all surgical procedure questions.

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: B

Rationale: The correct answer is B: Safety of the immediate environment. This is crucial for the client's well-being and can impact their health. The nurse should assess for hazards like loose rugs, clutter, or slippery floors. This ensures a safe living environment for the client. The other choices (A, C, D) are not directly related to the client's immediate safety or well-being. The number of rooms in the house (A) is not as important as ensuring the safety of the environment. The frequency of home visits (C) can be planned later based on the initial assessment. The friendliness of the client and family (D) is important for building rapport but does not address the immediate safety concerns of the client.

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.