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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.
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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 respiratory patterns indicates increasing intracranial pressure in the brain stem?
- A. Slow, irregular respirations.
- B. Rapid, shallow respirations.
- C. Asymmetric chest excursion.
- D. Nasal flaring.
Correct Answer: A
Rationale: Slow, irregular respirations (e.g., Cheyne-Stokes or ataxic breathing) are indicative of brain stem dysfunction due to increasing intracranial pressure. Rapid, shallow respirations may indicate hypoxia, asymmetric chest excursion suggests mechanical issues, and nasal flaring is associated with respiratory distress, not specifically ICP.
A client with osteoporosis needs education about diet and ways to increase bone density. Which of the following should be included in the teaching plan? Select all that apply.
- A. Maintain a diet with adequate amounts of vitamin D, as found in fortified milk and cereals.
- B. Choose good calcium sources, such as figs, broccoli, and almonds.
- C. Use alcohol in moderation because a moderate intake has no known negative effects.
- D. None of the above
Correct Answer: A,B
Rationale: Vitamin D and calcium are essential for bone health. Excessive alcohol can reduce bone density, so moderation alone is insufficient.
The nurse is caring for a client receiving a unit of packed red blood cells (PRBCs). The client reports chills, and their oral temperature is 103° F (39.4° C). Which action should the nurse take first?
- A. Assess the client's blood pressure and heart rate
- B. Obtain blood cultures
- C. Pause the transfusion
- D. Notify the primary healthcare provider (PHCP)
Correct Answer: C
Rationale: Chills and a fever of 103°F during a PRBC transfusion suggest a possible febrile or hemolytic reaction. The first action is to pause the transfusion to prevent further administration of potentially problematic blood. Assessing vital signs, obtaining cultures, and notifying the provider follow after stopping the transfusion.
The nurse assesses the respiratory status of a client who is experiencing an exacerbation of chronic obstructive pulmonary disease (COPD) secondary to an upper respiratory tract infection. Which of the following findings would be expected?
- A. Normal breath sounds.
- B. Prolonged inspiration.
- C. Normal chest movement.
- D. Coarse crackles and rhonchi.
Correct Answer: D
Rationale: COPD exacerbation with infection produces coarse crackles and rhonchi from secretions and airway inflammation. Breath sounds are diminished, expiration is prolonged, and chest movement is reduced.