Correct Answer: D

Rationale: Step 1: Monitoring electrolytes is essential to assess for potential imbalances due to the use of sodium bicarbonate, which can lead to hypokalemia and hypocalcemia. Step 2: Hypokalemia and hypocalcemia can result in serious complications such as cardiac arrhythmias and muscle weakness. Step 3: By monitoring electrolytes, the nurse can detect imbalances early and intervene promptly to prevent adverse effects. Summary: A: Drinking excessive water can lead to electrolyte imbalances and is not directly related to the use of sodium bicarbonate. B: Administering NaHCO3 IV is not within the nurse's scope of practice and should be done based on physician's orders. C: Continuing sodium bicarbonate for nausea may not be appropriate without monitoring electrolytes to prevent potential imbalances.

Correct Answer: D

Rationale: The correct initial action to take after the patient falls is to assess the patient (Choice D). This is important to determine the extent of any injuries sustained, assess the patient's current condition, and identify any factors that may have contributed to the fall. By conducting a thorough assessment, the nurse can gather crucial information to inform the revision of the care plan. Consulting physical therapy (Choice A) may be necessary later on but is not the immediate priority. Establishing a new plan of care (Choice B) and setting new priorities (Choice C) should be based on the assessment findings, making Choice D the most appropriate initial action.

Correct Answer: A

Rationale: The correct answer is A: Observations of wound healing. This is the correct evaluative measure because it directly assesses the patient's response to nursing care, indicating the effectiveness of interventions. Wound healing is a tangible and visible indicator of the patient's overall health status and the success of nursing interventions. The other choices are incorrect: B: Daily blood pressure measurements do not solely indicate a patient's response to nursing care. Blood pressure can be affected by various factors unrelated to nursing interventions. C: Findings of respiratory rate and depth are important for assessing respiratory status but may not directly reflect the patient's response to nursing care. D: Completion of nursing interventions is a process measure and does not provide direct insight into the patient's response to care.

Correct Answer: C

Rationale: The normal range for intraocular pressure (IOP) is approximately 10-21 mm Hg. Choice C has an IOP of 11 mm Hg, falling within this normal range, making it the correct answer. Choices A, B, and D are outside the normal range, with A being too low and B and D being too high, indicating abnormal IOP levels. Choice A (8 mm Hg) is below the normal range, while choices B (25 mm Hg) and D (28 mm Hg) are above the normal range, therefore, they are incorrect answers.

Correct Answer: A

Rationale: The correct answer is A: Platelet count, prothrombin time, and partial thromboplastin time. These parameters are essential in monitoring DIC because platelet count reflects the risk of bleeding, while prolonged prothrombin time and partial thromboplastin time indicate impaired clotting function, which is characteristic of DIC. Explanation for why other choices are incorrect: - Choice B: Blood glucose levels and WBC count are not specific indicators for DIC monitoring. - Choice C: Thrombin time, calcium levels, and potassium levels do not directly assess clotting abnormalities associated with DIC. - Choice D: While fibrinogen level is important in DIC, WBC count alone is not a specific indicator for monitoring DIC.