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The rate at which I.V. fluids are infused is based on the burn client's:
- A. I.V. and body surface area (BSA) burned.
- B. Total body weight and BSA burned.
- C. Total BSA and BSA burned.
- D. Height and weight and BSA burned.
Correct Answer: B
Rationale: The Parkland Formula uses total body weight and percentage of BSA burned to calculate fluid requirements, ensuring adequate resuscitation based on burn severity.
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The nurse is planning to teach incisional care to a client before discharge. Which of the following instructions should be included?
- A. Do not touch your incision before your next appointment.
- B. Clean your incision three times a day with hydrogen peroxide and water.
- C. Do not be concerned about uneven lumps under the suture lines.
- D. If the staples don't come out by themselves before your next appointment, the surgeon will remove them.
Correct Answer: C
Rationale: Uneven lumps under suture lines are normal due to tissue healing and swelling. This reassurance prevents unnecessary worry. Hydrogen peroxide is not routinely recommended, and staples are typically removed by the surgeon.
A client who had a total hip replacement 2 days ago has developed an infection with a fever. The nursing diagnosis of fluid volume deficit related to diaphoresis is made. Which of the following is the most appropriate outcome?
- A. The client drinks 2,000 mL of fluid per day.
- B. The client understands how to manage the incision.
- C. The client's bed linens are changed as needed.
- D. The client's skin remains cool throughout hospitalization.
Correct Answer: A
Rationale: Drinking 2,000 mL of fluid daily addresses fluid volume deficit due to diaphoresis.
An older adult client in stage 2 of Parkinson's disease is being discharged with cellulitis of the right lower extremity. Which of the following nursing diagnoses will guide the discharge teaching? Select all that apply.
- A. Ineffective tissue perfusion related to decreased cardiac output.
- B. Impaired skin integrity related to barrier changes of the skin.
- C. Risk for injury related to environmental hazards.
- D. Impaired verbal communication related to dysarthria.
- E. Security intolerance related to painful lower extremity.
Correct Answer: B,C
Rationale: Cellulitis causes impaired skin integrity due to infection and inflammation. Parkinson's increases fall risk, supporting risk for injury. Other options are less directly related.
The nurse is planning care for a client with a femoral fracture who is in balanced suspension traction. Which of the following would the nurse be least likely to include in the plan of care?
- A. Use of a fracture bedpan.
- B. Checks for redness over the ischial tuberosity.
- C. Elevation of the head of bed no more than 25 degrees.
- D. Personal hygiene with a complete bed bath.
Correct Answer: C
Rationale: Elevating the head of the bed beyond 25 degrees can disrupt traction alignment, making it least appropriate.
The emergency department (ED) nurse cares for a client receiving prescribed warfarin and reports dizziness, black tarry stools, and bloody gums. The international normalized ratio (INR) returns at 5 (0.9-1.2 seconds). The nurse anticipates the primary healthcare provider (PHCP) will prescribe which blood product?
- A. Packed red blood cells (PRBCs)
- B. Platelets
- C. Granulocytes
- D. Fresh frozen plasma (FFP)
Correct Answer: D
Rationale: An INR of 5 indicates significant anticoagulation from warfarin, increasing bleeding risk (evidenced by tarry stools and bloody gums). FFP provides clotting factors to reverse warfarin’s effects. PRBCs address anemia, platelets address thrombocytopenia, and granulocytes treat infections, none of which are primary here.