After a Whippie procedure for cancer of the pancreas, a client is to receive the following intravenous (IV) fluids over 24 hours; 1000 ml D5W; 0.5 liter normal saline; 1500 ml D5NS. In addition, an antibiotic piggyback in 50 ml D5W is ordered every 8 hours. The nurse calculates that the clients IV fluid intake Tor 24 hours will be:

Correct Answer: D

Rationale: The correct answer is D (3750ml) because the client will receive 1000ml D5W + 500ml normal saline + 1500ml D5NS + 50ml antibiotic every 8 hours x 3 times in 24 hours (50ml x 3 = 150ml). Adding these together gives a total of 1000ml + 500ml + 1500ml + 150ml = 3150ml. Therefore, the client's IV fluid intake for 24 hours will be 3150ml.

Correct Answer: C

Rationale: The rule of nines is a method used to estimate the extent of burns on a patient's body. According to this rule, each major body part is assigned a percentage value that represents the total body surface area (TBSA). In this case, Mr. Kawasaki has second-degree burns on his right leg and arm (9% each) and left leg (9%) and third-degree burns on his left arm (9%). Adding these percentages together, we get a total of 36%, which corresponds to the extent of burn on Mr. Kawasaki's body. Choice A (18%) is incorrect because it only considers one arm and one leg, neglecting the other affected areas. Choice B (45%) is incorrect as it overestimates the extent of burns by including additional body parts not affected. Choice D (54%) is also incorrect as it includes more body parts than those actually burned. Therefore, the correct answer is C (36%) as it accurately reflects the distribution of burns based

Correct Answer: B

Rationale: The correct answer is B because optimum sleep helps regulate breathing patterns during an EEG. Waking the client at midnight allows them to have a full night's rest, ensuring they are well-rested and their breathing is stable for accurate EEG results. Choice A is incorrect as excess sleep does not affect nervousness. Choice C is incorrect as waking the client does not help them fall asleep naturally during the EEG. Choice D is incorrect as headache prevention is not directly related to waking the client at midnight.

Correct Answer: D

Rationale: The correct answer is D because it offers the patient autonomy by providing a choice between brushing their teeth independently or having assistance. This empowers the patient to make decisions regarding their personal hygiene, promoting independence and self-esteem. Choice A does not offer a choice or empower the patient. Choice B focuses solely on the location of the toothbrush and does not address the patient's needs. Choice C does not provide the patient with a sense of control over their hygiene routine. By contrast, choice D acknowledges the patient's needs, offers a choice, and encourages independence.

Correct Answer: C

Rationale: The correct answer is C: Hypoventilation. In chronic respiratory acidosis, the lungs cannot effectively eliminate carbon dioxide, leading to an accumulation of CO2 in the blood, causing acidosis. Hypoventilation results in decreased removal of CO2, exacerbating the acidosis. A: Hyperventilation would lead to respiratory alkalosis, not acidosis. B: Loss of acid by kidneys would result in metabolic alkalosis, not respiratory acidosis. D: Loss of base by kidneys would lead to metabolic acidosis, not respiratory acidosis. In summary, the main issue in chronic respiratory acidosis is inadequate elimination of CO2 due to hypoventilation, leading to acidosis.

Correct Answer: C

Rationale: The correct answer is C, veins deep in the lower extremities, due to stasis and immobility in the legs causing blood to pool and predispose to thrombus formation. This is known as deep vein thrombosis (DVT). Veins deep in the upper extremities (A) are less commonly affected. The popliteal vein of the leg (B) is a common site for DVT, but it is not the most commonly affected. Veins connected to the heart (D) are arteries, not veins, and are not typically involved in thrombophlebitis.

Correct Answer: C

Rationale: The correct answer is C because older clients with AIDS have a faster progression of the disease due to age-related changes in the immune system, making them more vulnerable to complications. This results in a greater need for care compared to younger counterparts. Choice A is incorrect as lack of balanced diet and activity does not directly relate to the progression of AIDS. Choice B is incorrect as knowledge about disorders is not the main factor affecting the level of care needed. Choice D is incorrect as adherence to therapy is important but not the main reason older clients need more care.

Correct Answer: D

Rationale: The correct answer is D because a disease process involving the sacral plexus can impact bladder function (choice A), sexual activity (choice B), and bowel management (choice C). The sacral plexus is responsible for innervating pelvic organs and lower limb muscles, so dysfunction in this area can lead to issues in these functions. Bladder problems can manifest as urinary retention or incontinence, sexual activity may be affected due to changes in sensation or muscle control, and bowel management can be disrupted leading to constipation or incontinence. Therefore, assessing all these areas is crucial to understand the full impact of the disease process on the individual's quality of life.

Correct Answer: C

Rationale: The correct answer is C: Bluish urine. During lymphangiography, a contrast dye is injected into the lymphatic vessels, which can be excreted through the urine, causing it to appear bluish temporarily. This change is harmless and resolves on its own. Incorrect Answers: A: Purplish stools - This is not a common side effect of lymphangiography. B: Redness of the upper part of the feet - Redness is not typically associated with this procedure. D: Coldness of the soles - Coldness is not a known temporary change resulting from lymphangiography.