Correct Answer: D

Rationale: The correct answer is D: Fever. Following splenectomy, patients are at risk for OPSI due to impaired immune response. Fever is a key symptom of infection and should alert the nurse to this possibility. Bruising around the operative site (A) is expected post-surgery. Pain (B) is common after surgery and may not specifically indicate OPSI. Irritability (C) is a vague symptom and not specific to OPSI. In summary, fever is the most concerning symptom as it can indicate an underlying infection in a postsplenectomy patient.

Correct Answer: A

Rationale: The correct answer is A: Maintain strict records of intake and output. This is the best way to assess fluid balance in a burn patient because it provides quantitative data on fluid intake and output, helping to monitor for fluid imbalance. Monitoring skin turgor (B) is unreliable in burn patients due to skin damage. Weighing the client daily (C) may not accurately reflect fluid balance changes. Checking for edema (D) is not specific to assessing fluid balance in burn patients. Maintaining intake and output records allows for precise monitoring and early detection of fluid shifts, making it the most appropriate choice.

Correct Answer: C

Rationale: Step 1: The nurse should explain that bladder irrigation is necessary to prevent blood clots from occluding the catheter after a TURP procedure. Step 2: Without irrigation, blood clots could block the catheter, leading to urinary retention and potential complications. Step 3: This explanation addresses the patient's concern about increased pain and highlights the importance of the irrigation in maintaining proper urine flow. Step 4: Choice A is incorrect because the primary purpose of irrigation is not to stop bleeding but to prevent clot formation. Choice B is incorrect because the irrigation is not for administering antibiotics. Choice D is incorrect as it does not address the issue of clot formation.

Correct Answer: A

Rationale: The correct answer is A: Trousseau's sign. A serum calcium level of 7.2mg/dl indicates hypocalcemia. Trousseau's sign is a clinical manifestation of hypocalcemia, characterized by carpal spasm induced by inflating a blood pressure cuff above systolic pressure. This occurs due to increased neuromuscular excitability from low calcium levels. Hegar's sign (B) is associated with pregnancy, Homan's sign (C) is a clinical test for deep vein thrombosis, and Goodell's sign (D) is a softening of the cervix during pregnancy. These signs are not relevant to a client with hypocalcemia.

Correct Answer: C

Rationale: The correct answer is C: Ask the patient about the facial grimacing with movement. This is the initial action because the discrepancy between the patient's verbal pain level and non-verbal cues needs clarification. By directly asking the patient about the facial grimacing, the nurse can gather more information to assess the actual pain level accurately. This step ensures a comprehensive understanding of the patient's pain experience and guides further interventions. Incorrect choices: A: Proceed to the next patient’s room to make rounds - This choice neglects the need to address the discrepancy in the patient's pain assessment. B: Determine the patient does not want any pain medicine - Assuming the patient's preference without further assessment can lead to inadequate pain management. D: Administer the pain medication ordered for moderate to severe pain - Without clarifying the reason behind the facial grimacing, administering pain medication may not be appropriate and could result in unnecessary medication use.