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 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: B

Rationale: The correct answer is B because having the patient rate her fatigue on a scale allows for a subjective assessment directly from the patient, providing valuable insight into the severity and impact of fatigue on her daily life. This approach considers the patient's perspective, which is crucial in understanding her experience and tailoring interventions. Choice A (observing activity level) may not accurately capture the subjective experience of fatigue. Choice C (monitoring vital signs) does not directly assess fatigue but rather general health status. Choice D (monitoring hemoglobin and hematocrit values) can indicate anemia but may not fully capture the patient's fatigue experience.

Correct Answer: A

Rationale: The correct answer is A: Reassess the patient and situation. The nurse should reassess to determine the cause of the pressure ulcer, evaluate the effectiveness of the current turning schedule, and identify any contributing factors. This allows for a more targeted intervention plan. B: Incorrect. Simply increasing the frequency of turning may not address the underlying issue causing the pressure ulcer. C: Incorrect. Delegating turning to nursing assistive personnel without reassessment may not address the root cause of the pressure ulcer. D: Incorrect. Applying medication without reassessment may not address the underlying cause of the pressure ulcer and could potentially worsen the condition.

Correct Answer: C

Rationale: The correct order of priority for nursing actions for a new laryngectomee is: ii.Set up a visit from a well-adjusted laryngectomee, iii.Maintain a patent airway, iv.Control postoperative pain, i.Assist with ambulation. Setting up a visit from a well-adjusted laryngectomee comes first to provide emotional support and guidance. Maintaining a patent airway is crucial for breathing. Controlling postoperative pain is important for comfort. Assisting with ambulation is necessary but can be done after ensuring the other priorities are addressed. Other choices are incorrect because they do not prioritize emotional support, airway maintenance, and pain control before assisting with ambulation.

Correct Answer: C

Rationale: The correct answer is C - Observing closely for signs of respiratory distress. In encephalitis, there is a risk of respiratory compromise due to brain inflammation affecting the respiratory center. Monitoring for signs of respiratory distress is critical to intervene promptly if breathing becomes compromised. A - Measuring fluid intake and output is important but not as critical as monitoring respiratory distress in encephalitis. B - Evaluating ventilation capacity and lung sounds is important, but close observation for respiratory distress takes precedence for immediate intervention. D - Administering an indwelling urethral catheter is not directly related to the client's immediate critical needs in encephalitis.

Correct Answer: C

Rationale: The correct answer is C: Night sweats. In Hodgkin's disease category B, the presence of night sweats signifies more advanced disease and higher tumor burden. Night sweats are a B-symptom, along with fever and weight loss, indicating systemic symptoms. Anemia (choice B) and thrombocytopenia (choice D) are not specific to Hodgkin's disease category B and can be present in various other conditions. Fever (choice A) is not exclusive to Hodgkin's disease category B and can occur in many infections and inflammatory conditions. Night sweats are specifically associated with Hodgkin's disease and are a key indicator of disease severity in this context.

Correct Answer: C

Rationale: The correct answer is C because it clearly states a measurable outcome by specifying that the client will be able to list five symptoms of infection. This outcome is specific, measurable, achievable, relevant, and time-bound (SMART). Choice A lacks specificity and measurability. Choice B is vague and does not provide a quantifiable measure of success. Choice D does not specify who will be observing the symptoms or how they will be documented. Overall, choice C stands out as the most appropriate outcome as it is clear, achievable, and directly related to assessing the client's understanding of infection symptoms.

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.