The nurse is caring for a patient who has a massive burn injury and possible

Correct Answer: A

Rationale: The correct answer is A because in a patient with a massive burn injury, the most concerning assessment data would be related to the extent and depth of the burns, the presence of airway compromise, and signs of infection or sepsis. These factors can significantly impact the patient's prognosis and require immediate intervention. Choice B is not the most concerning as urine output of 30 mL/hr may be expected in a burn patient due to fluid shifts and decreased perfusion. Choice C indicates hypotension, which is concerning but not as immediate as assessing the extent and severity of the burns. Choice D, while indicating inadequate fluid intake, is not the most critical assessment in this scenario compared to evaluating the burn injury itself and potential complications. Therefore, choice A is the correct answer as it focuses on the most critical aspect of care for a patient with a massive burn injury.

Correct Answer: A

Rationale: The correct answer is A: Skim Milk. Skim milk is high in phosphorus, which is not suitable for a patient on a low phosphate diet due to renal failure. The rationale is to limit phosphorus intake to prevent further complications. Grape juice (B), tea (C), and mixed green salad (D) are lower in phosphorus compared to skim milk and can be included in a low phosphate diet.

Correct Answer: B

Rationale: The correct answer is B: Test for presence of Chvostek's sign. After a thyroidectomy, tingling around the mouth could indicate hypocalcemia, which can lead to tetany. Chvostek's sign is a test for hypocalcemia, where facial twitching occurs when the facial nerve is tapped. This assessment is crucial to identify potential complications and initiate timely interventions. Incorrect choices: A: Verify the serum potassium level - While electrolyte imbalances can occur post-thyroidectomy, hypocalcemia is more likely to cause the tingling sensation around the mouth. C: Observe for blood on the neck dressing - While assessing for bleeding is important, it does not directly address the tingling sensation reported by the patient. D: Confirm a prescription for thyroid replacement - While important for long-term management post-thyroidectomy, it does not address the immediate concern of tingling sensation related to hypocalcemia.

Correct Answer: B

Rationale: The correct answer is B because an increase in weight indicates fluid retention. In this case, the weight increased from 97.5 kg to 99 kg, suggesting a gain of 1.5 kg, which corresponds to fluid retention of 1.5 liters. Choices A, C, and D are incorrect because they do not accurately reflect the situation described in the question. Choice A does not account for fluid retention, choice C suggests fluid loss despite weight gain, and choice D mentions insensible losses which are not relevant to the weight gain observed.

Correct Answer: D

Rationale: The correct answer is D because dialysis disequilibrium syndrome is a complication that can occur during hemodialysis, presenting with symptoms like headache due to rapid changes in electrolyte levels and osmolarity. The other choices are incorrect because: A: Symptoms mentioned are not specific to dialyzer membrane incompatibility. B: Shift in potassium levels might cause symptoms like muscle weakness or cardiac arrhythmias, not specifically headache. C: A shift in potassium levels is not the primary cause of a headache during hemodialysis.