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A client who received complete thickness burns at 7:30 a.m. was rushed to the emergency room where IV therapy with Lactated Ringer's was begun. He is to receive $8,000 \mathrm{~mL}$ of solution in 24 hours. According to the Parkland formula, how much solution should he receive by 11:30 p.m.?
- A. 4,000 mL
- B. 5,000 mL
- C. 6,000 mL
- D. 7,000 mL
Correct Answer: C
Rationale: The Parkland formula states half the total fluid (4,000 mL) is given in the first 8 hours (by 3:30 p.m.), and the remaining 4,000 mL over the next 16 hours. By 11:30 p.m. (16 hours post-burn), the client should have received 6,000 mL.
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The nurse is reviewing laboratory test results for an 80-year-old client who has a methicillin-resistant Staphylococcus aureus infection and is receiving vancomycin. Which of the following test results would require immediate follow-up?
- A. elevated BUN
- B. decreased serum iron level
- C. decreased serum triglyceride level
- D. elevated capillary blood glucose level
Correct Answer: A
Rationale: Elevated BUN (A) may indicate nephrotoxicity, a serious side effect of vancomycin requiring immediate follow-up. Decreased iron (B) or triglycerides (C) are not directly related to vancomycin toxicity. Elevated glucose (D) may need monitoring but is less urgent.
A client continually repeats phrases that others have just said. The nurse recognizes this behavior as
- A. Autistic
- B. Echopraxis
- C. Echolalia
- D. Catatonic
Correct Answer: C
Rationale: Echolalia is repeating words or phrases heard before, often seen in certain psychiatric or developmental conditions.
A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidyl glycerol is noted. The nurse's assessment of this data is:
- A. The infant is at low risk for congenital anomalies.
- B. The infant is at high risk for intrauterine growth retardation.
- C. The infant is at high risk for respiratory distress syndrome.
- D. The infant is at high risk for birth trauma.
Correct Answer: C
Rationale: An L/S ratio of 1:1 and presence of phosphatidyl glycerol suggest immature lungs, indicating a high risk for respiratory distress syndrome, so C is correct. Answers A, B, and D are not directly related to these findings.
A client who is being evaluated for suspected ectopic pregnancy reports sudden-onset, severe, right lower abdominal pain and dizziness. Which of the following additional assessment findings will the nurse anticipate if the client is experiencing a ruptured ectopic pregnancy? Select all that apply.
- A. Blood pressure 82/64 mm Hg
- B. Crackles on auscultation
- C. Distended jugular veins
- D. Pulse 120/min
- E. Shoulder pain
Correct Answer: A, D, E
Rationale: Low blood pressure (A), tachycardia (D), and shoulder pain (E) indicate hemorrhage from a ruptured ectopic pregnancy. Crackles (B) and jugular vein distension (C) are unrelated.
The nurse is talking with the parent of a 22-month-old client. The parent states, 'I am worried about my child's thumb-sucking and its effects on tooth alignment.' Which of the following responses would be appropriate for the nurse to make? Select all that apply.
- A. Newer research demonstrates that thumb-sucking has little effect on a child's dentition.'
- B. Offer a security item such as a blanket to help your child self-soothe without thumb-sucking.'
- C. Provide positive reinforcement such as a sticker chart when your child avoids thumb-sucking.'
- D. The likelihood of needing braces because of thumb-sucking is significant when the behavior persists beyond 12 months of age.'
- E. The risk of malocclusion increases when thumb-sucking persists beyond the eruption of permanent teeth.'
Correct Answer: B, C, E
Rationale: Offering a security item (B), positive reinforcement (C), and noting malocclusion risk after permanent teeth erupt (E) are appropriate. Thumb-sucking has minimal effect before permanent teeth (A), and braces after 12 months (D) is exaggerated.