The nurse is admitting a patient to the clinical unit from surgery. Being alert to potential fluid volume alterations, what assessment data will be important for the nurse to monitor to identify early changes in the patient’s postoperative fluid volume (select all that apply)?

Correct Answer: A

Rationale: In the context of pharmacology and nursing practice, monitoring fluid volume status is crucial postoperatively to ensure patient safety and prevent complications. The correct answer is A) Intake and output. Intake and output monitoring provides direct information about the fluid balance in the body, helping the nurse assess for any significant changes that may indicate fluid volume alterations. Skin turgor (option B) is a valuable assessment for dehydration but may not provide early signs of fluid volume alterations in a postoperative patient. Lung sounds (option C) are more indicative of respiratory function rather than fluid volume status. Respiratory rate (option D) is important but may not be as sensitive as intake and output monitoring in detecting early changes in fluid volume. Educationally, understanding the rationale behind choosing intake and output as a priority assessment helps students and nurses comprehend the significance of fluid balance in postoperative care. Emphasizing the importance of accurate assessment techniques can enhance patient outcomes and promote critical thinking skills in clinical practice.

Correct Answer: C

Rationale: The correct answer is C because Class I and Class II MHC proteins present antigens to T-cell receptors for immune response activation. Class I MHC presents endogenous antigens to CD8+ T cells, while Class II MHC presents exogenous antigens to CD4+ T cells. Choice A is incorrect because MHC proteins do not transduce signals. Choice B is incorrect because MHC proteins do not mediate immunoglobulin class switching. Choice D is incorrect because MHC proteins do not directly stimulate interleukin production.

Correct Answer: C

Rationale: The correct answer is C because an antigenic determinant is not a paratope, but an epitope. Epitope is a small portion of a macromolecule that is recognized by antibodies. Variable region domains of antibodies contain the antigen recognition site. The class of an immunoglobulin is indeed determined by its heavy chain. Therefore, C is the only statement that is not true.

Correct Answer: C

Rationale: The correct answer is C because long-term immobilization can indeed cause permanent disability in the case of a grade 2 sprain. Prolonged immobilization can lead to muscle atrophy, joint stiffness, and decreased range of motion, which can result in long-term disability. Choice A is incorrect because adequate circulation is more related to prolonged immobilization, not short-term removal for evaluation. Choice B is incorrect as edema is a short-term concern and not a direct result of long-term immobilization. Choice D is incorrect as there is no indication that a heavier cast will be used.

Correct Answer: C

Rationale: The correct answer is C because if the patient's feet are against the footboard in Buck traction, it can cause pressure ulcers and compromise circulation. Repositioning the patient is necessary to ensure proper alignment and prevent complications. Incorrect choices: A: The patient's heels not touching the mattress can be due to the traction pulling the legs in a specific position. B: Rewrapping the elastic bandages may be necessary for proper traction maintenance but doesn't indicate immediate need for repositioning. D: The weights hanging free is a normal finding in Buck traction and indicates proper traction application.