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Questions 176

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Question 1 of 5

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.?

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.

Question 2 of 5

An adult is scheduled for a total laryngectomy. When preparing the client for surgery, it is essential for the nurse to take which of the following actions?

Correct Answer: C

Rationale: A laryngectomy removes the voice box, requiring alternative communication; assessing literacy ensures post-op communication via writing, critical for care planning.

Question 3 of 5

The nurse is caring for a client who has congestive heart failure. Which finding indicates that her condition is getting worse?

Correct Answer: B

Rationale: A decrease in blood pressure suggests worsening cardiac output in congestive heart failure, indicating decompensation.

Question 4 of 5

The nurse is caring for an 87 year-old client with urinary retention. Which finding should be reported immediately?

Correct Answer: A

Rationale: Fecal impaction. The nurse should report fecal impaction or constipation which can cause obstruction of the bladder outlet. Bladder outlet obstruction is a common cause of urine retention in the elderly.

Question 5 of 5

The parents of a 15 month-old child asks the nurse to explain their child's lab results and how they show the child has iron deficiency anemia. The nurse's best response is

Correct Answer: B

Rationale: Your child has fewer red blood cells that carry oxygen. This provides a simple explanation of iron deficiency anemia.

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