Nokea
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.]
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When a client is receiving a cephalosporin, the nurse must monitor the client for which of the following?
- A. Drug-induced hemolytic anemia.
- B. Purpura.
- C. Infectious emboli.
- D. Ecchymosis.
Correct Answer: A
Rationale: Cephalosporins can rarely cause drug-induced hemolytic anemia by triggering an immune response that destroys red blood cells. The nurse should monitor for signs such as jaundice, dark urine, or a drop in hemoglobin. Purpura, infectious emboli, and ecchymosis are not commonly associated with cephalosporin use.
The client with acute lymphocytic leukemia (ALL) is at risk for infection. What should the nurse do?
- A. Place the client in a private room.
- B. Have the client wear a mask.
- C. Have staff wear gowns and gloves.
- D. Restrict visitors.
Correct Answer: A
Rationale: Clients with ALL are immunocompromised due to neutropenia, increasing infection risk. Placing the client in a private room reduces exposure to pathogens. Masks, gowns, and visitor restrictions may be used in severe cases, but a private room is the first step.
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.
The right hand of a client with multiple sclerosis trembles severely whenever she attempts a purposeful act, such as picking up her coffee cup or buttoning her dress. Which is the best legal documentation in nurses' notes of the chart for this client assessment?
- A. "Has an intention tremor of the right hand."
- B. "Right-hand tremor worsens with purposeful acts."
- C. "Needs assistance with dressing and eating due to severe trembling and clumsiness."
- D. "Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup."
Correct Answer: D
Rationale: The most detailed and accurate documentation is: "Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup," as it describes the intention tremor specifically and legally.
In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client?
- A. Keeping the client flat on one side or the other.
- B. Elevating the head of the bed to 30 degrees.
- C. Logrolling or turning as a unit when turning.
- D. Keeping the neck in a neutral position.
Correct Answer: A
Rationale: Keeping the client flat is contraindicated after a posterior fossa craniotomy, as it increases ICP. Elevating the head, logrolling, and neutral neck positioning promote venous drainage and spinal alignment, reducing ICP risk.