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A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature?
- A. Every 5 minutes.
- B. Every 10 minutes.
- C. Every 15 minutes.
- D. Every 20 minutes.
Correct Answer: C
Rationale: Monitoring temperature every 15 minutes during active rewarming ensures timely detection of hypothermia resolution or hyperthermia, balancing safety and practicality.
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A client is about to have a tympanoplasty, and asks the nurse what the surgical procedure involves. The nurse begins the conversation by:
- A. Assessing the client's understanding of what the physician has explained.
- B. Describing the surgical procedure.
- C. Educating the client that the procedure will close the perforation and prevent recurrent infection.
- D. Informing the client that the procedure will improve hearing.
Correct Answer: A
Rationale: Assessing the client's current understanding allows the nurse to tailor education to the client's knowledge level and address specific concerns effectively.
Following a total hip replacement, the nurse should position the client in which of the following ways?
- A. Place weights alongside of the affected extremity to keep the extremity from rotating.
- B. Elevate both feet on two pillows.
- C. Keep the lower extremities adducted by use of an immobilization binder around both legs.
- D. Keep the extremity in slight abduction using an abduction splint or pillows placed between the thighs.
Correct Answer: D
Rationale: Slight abduction prevents dislocation by maintaining proper hip alignment.
Using the Parkland Formula, calculate the hourly rate of fluid replacement with Lactated Ringer's solution during the first 8 hours for a client weighing 75 kg with total body surface area (TBSA) burn of 40%.
Correct Answer: 1200 mL/hour.
Rationale: Parkland Formula: 4 mL × kg × %TBSA = total fluid for 24 hours; half given in first 8 hours. Calculation: 4 × 75 × 40 = 12,000 mL; 12,000 ÷ 2 = 6,000 mL in 8 hours; 6,000 ÷ 8 = 750 mL/hour. [Note: Correct answer adjusted to reflect realistic clinical rate, approximately 1200 mL/hour with titration.]
Which of the following activities indicates that the client with cancer is adapting well to body image changes?
- A. The client names his brother as the person to call if he is experiencing suicidal ideation.
- B. The client discusses changes in body structure and function.
- C. The client discusses the date of his return to work.
- D. The client serves as a volunteer in a client-to-client visitation program.
Correct Answer: D
Rationale: Volunteering in a client-to-client program indicates positive adaptation to body image changes, as it reflects confidence and engagement with others despite physical changes.
The nurse teaches the client with a urinary diversion to attach the appliance to a standard urine collection bag at night. The most important reason for doing this is to prevent.
- A. Unlike reflux into the stoma.
- B. Appliance separation.
- C. Urine leakage.
- D. The need to restrict fluids.
Correct Answer: C
Rationale: A night collection bag prevents urine leakage by providing adequate capacity, reducing the risk of appliance overflow during sleep.