Nokea
A client weighing 76 kg is admitted at 0600 with a TBSA burn of 40%. Using the Parkland formula, the client's 24-hour intravenous fluid replacement should be:
- A. 6,080 ml
- B. 9,120 ml
- C. 12,160 ml
- D. 15,180 ml
Correct Answer: C
Rationale: The Parkland formula is 4 ml × kg × TBSA = 24-hour fluid requirement, or 4 × 76 × 40 = 12,160 ml. Answer A is the fluid requirement for the first 8 hours after burn injury, so it's incorrect. Answer B is incorrect because it's the fluid requirement for 16 hours after burn injury. Answer D is an excessive amount given the client's weight and TBSA, so it's incorrect.
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A patient 48 hours after surgery for a hernia repair.
The nurse checks the incision of a patient 48 hours after surgery for a hernia repair. Which of the following findings would indicate a possible complication?
- A. There is swelling under the sutures.
- B. There is crusting around the incision line.
- C. The incision line is red.
- D. The incision line is approximated.
Correct Answer: C
Rationale: Strategy: Determine the significance of each answer choice. (1) slight swelling is expected during healing (2) slight crusting of incision line is normal (3) correct-should be pink, not red, indicates possible infection, other signs include increased warmth, tenderness, pain, and purulent or odorous drainage (4) shows healing is taking place
The nurse is caring for a client who was in a motor vehicle accident. His blood pressure is dropping rapidly. What should the nurse observe the client for before placing the client in shock position?
- A. Long bone fractures
- B. Air embolus
- C. Head injury
- D. Thrombophlebitis
Correct Answer: C
Rationale: Shock position (legs elevated) is contraindicated in head injury due to increased intracranial pressure risk. Observing for head injury ensures safety before positioning.
Included in teaching the client with tuberculosis taking isoniazid (INH) about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?
- A. Liver function
- B. Kidney function
- C. Blood sugar
- D. Cardiac enzymes
Correct Answer: A
Rationale: Liver function. INH can cause hepatocellular injury and hepatitis. This side effect is age-related and can be detected with regular assessment of liver enzymes, which are released into the blood from damaged liver cells.
A male client's behavior begins to escalate into aggressive behavior.
The nurse is caring for clients on the psychiatric unit. Suddenly, a male client's behavior begins to escalate into aggressive behavior. It would be MOST important for the nurse to take which of the following actions?
- A. Utilize an organized team to place the client in seclusion.
- B. Leave the client alone in his room to identify feelings of anger.
- C. Redirect the client to a quiet activity to divert his attention and not disturb the other clients.
- D. Assist the client to identify and express his feelings of increasing anxiety, frustration, and anger.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) nurse can be helpful in using psychological/communication strategies before utilizing seclusion (2) leaving the client alone can become potentially dangerous to the client and the property (3) encouraging the client to become involved in a quiet activity might further escalate his frustration and anger because the ability to focus and concentrate is diminished due to an elevated anxiety level (4) correct-as client's anger begins to escalate, nurse can be helpful in using psychological/communication strategies before utilizing seclusion
The nurse assesses the use of coping mechanisms by an adolescent 1 week after the client had a motor vehicle accident resulting in multiple serious injuries. Which of these characteristics are most likely to be displayed?
- A. Ambivalence, dependence, demanding
- B. Denial, projection, regression
- C. Intellectualization, rationalization, repression
- D. Identification, assimilation, withdrawal
Correct Answer: B
Rationale: Helplessness and hopelessness may contribute to regressive, dependent behavior which often occurs at any age with hospitalization. Denying or minimizing the seriousness of the illness is used to avoid facing the worst situation. Recall that denial is the initial step in the process of working through any loss.