A febrile patient’s fluid output is in excess of normal because of diaphoresis. The nurse should plan fluid replacement based on the knowledge that insensible losses in an afebrile person are normally not greater than:

Correct Answer: C

Rationale: The correct answer is C (600ml/24hr) because insensible fluid losses in an afebrile person are typically around 600ml per 24 hours. Insensible losses include water lost through the skin as sweat and through the lungs during respiration. These losses are not easily quantifiable but are estimated to be around 600ml/day in normal circumstances. Choices A, B, and D are incorrect because they are either too low (A and B) or too high (D) compared to the normal range of insensible fluid losses. Selecting C as the correct answer is based on the understanding of physiological principles related to fluid balance and normal body functions.

Correct Answer: A

Rationale: The correct answer is A because hyperventilating James with 100% oxygen before and after suctioning can lead to oxygen toxicity. The rationale is as follows: 1. Hyperventilation with 100% oxygen can lead to increased oxygen levels in the blood, potentially causing oxygen toxicity. 2. Oxygen toxicity can result in lung damage and other complications. 3. It is not recommended to administer 100% oxygen continuously, especially in high concentrations. Therefore, Wilma committing an error by hyperventilating James with 100% oxygen. Other choices are incorrect because B is a common practice to help loosen secretions, C is correct suctioning technique, and D is a reasonable frequency for suctioning depending on the client's condition.

Correct Answer: C

Rationale: The correct answer is C, the 35-year-old with kidney failure. Patients with kidney failure are at high risk for fluid volume overload due to the kidneys' inability to properly regulate fluid balance. This can lead to accumulation of excess fluids in the body, causing edema, hypertension, and heart failure. In contrast, choices A, B, and D are not at as high risk for fluid volume overload as patients with kidney failure, as their conditions do not directly impact fluid regulation in the body.

Correct Answer: C

Rationale: The correct answer is C: Puffiness at the site. This indicates infiltration of the infusion, where the medication or fluid leaks into the surrounding tissue instead of entering the bloodstream. Puffiness is a sign of fluid accumulation due to the infiltration. Redness at the site (A) may indicate infection, pain (B) can be due to various reasons, and exudate (D) may suggest infection or irritation, but they are not specific to infiltration. Infiltration assessment involves checking for swelling, coolness, and blanching around the infusion site.

Correct Answer: D

Rationale: The correct answer is D: Presence of laryngospasm. Laryngospasm is a serious complication of trauma to the upper airway that can lead to airway obstruction. Assessing for laryngospasm is crucial to ensure the client's airway remains patent. Pain when talking (A) is more related to vocal cord injury, increased nasal swelling (B) is a symptom of nasal trauma, and burning in the throat (C) may indicate pharyngeal injury, but laryngospasm (D) directly affects airway patency in upper airway trauma cases.