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Question 1 of 5

A very tall, heavy-set man is admitted. The nurse is taking vital signs. Which statement is correct concerning taking the blood pressure?

Correct Answer: C

Rationale: An extra-large cuff ensures accurate blood pressure measurement in large individuals; a standard cuff falsely elevates readings. Adjusting readings or lying down is unnecessary.

Question 2 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 3 of 5

The nurse has reinforced teaching with a client who has rheumatoid arthritis and is receiving methotrexate. Which of the following statements by the client would require follow-up?

Correct Answer: D

Rationale: Avoiding alcohol (
A), preventing pregnancy (
B), and avoiding crowds (
C) are correct. Avoiding folic acid (
D) is incorrect, as methotrexate often requires folic acid supplementation to reduce side effects.

Question 4 of 5

The nurse is caring for a client with hyperosmolar hyperglycemic state (HHS). The nurse should recognize which characteristic is most consistent with HHS?

Correct Answer: B

Rationale: Altered consciousness (
B) is a hallmark of HHS due to severe hyperglycemia and dehydration. Abdominal pain (
A) and Kussmaul respirations (
D) are more typical of DKA, and HHS is associated with type 2 diabetes (
C).

Question 5 of 5

A client just diagnosed with methicillin-resistant Staphylococcus aureus septic arthritis is receiving the first dose of IV vancomycin. Which finding is most concerning to the nurse?

Correct Answer: D

Rationale: Wheezing and hives (
D) indicate a possible anaphylactic reaction, the most concerning finding. Muscle pain (
A), flushing/pruritus (
B), and low blood pressure (
C) are less immediately life-threatening.

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