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A nurse is calculating the intake and output for a client over the last 8 hr. The client is receiving a continuous IV infusion at 150 mL/hr and had 4 oz of juice and 0.5 L of water.

How many mL of fluid should the nurse document as the client's intake for the last 8 hr? (Round your answer to the nearest whole number.)

Answer and Explanation

The Correct Answer is ["1820"]

1. IV fluids:

150 mL/hr * 8 hr = 1200 mL

2. Juice:

4 oz * 30 mL/oz = 120 mL

3. Water:

0.5 L * 1000 mL/L = 500 mL

Total intake:

1200 mL + 120 mL + 500 mL = 1820 mL

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Correct Answer is B

Explanation

A. Empty the urine drainage bag every 12 hours: While it's essential to empty the urine drainage bag regularly to prevent it from becoming too full, emptying it every 12 hours alone is not sufficient to prevent urinary tract infections (UTIs).
B. Drain the urine from the tubing before ambulation: Correct. Before the client ambulates or moves, the nurse should ensure that the urinary catheter's tubing is emptied. This prevents urine from flowing back into the bladder, reducing the risk of UTIs.
C. Use clean technique for urine specimen collection: While using clean technique during urine specimen collection is important for preventing contamination, it is not the primary action needed to prevent UTIs in a client with an indwelling urinary catheter.
D. Hang the urine drainage bag at the level of the bladder: While proper positioning of the drainage bag is essential for optimal urine flow and to prevent backflow, it alone is not sufficient to prevent UTIs.

A. Urine specific gravity 1.015 B. Hematocrit 42% C. Urine pH 6.5 D. BUN 5 mg/dL

Correct Answer is D

Explanation

A. A urine specific gravity of 1.015 is within the normal range (1.005–1.030). While fluid volume excess may lead to a lower specific gravity due to urine dilution, this value does not indicate fluid overload and is considered normal.
B. A hematocrit level of 42% is within the normal range for adults (men: 38–50%, women: 35–45%). Hematocrit levels tend to decrease in fluid volume excess due to hemodilution, but this value does not suggest fluid overload.
C. A urine pH of 6.5 is within the normal range (4.5–8.0). Urine pH reflects the acid-base balance rather than fluid status and is not a reliable indicator of fluid volume excess.
D. A BUN level of 5 mg/dL is below the normal range (10–20 mg/dL). In fluid volume excess, the dilution of blood plasma can lead to decreased BUN levels. This low BUN value, in conjunction with clinical symptoms, supports the diagnosis of fluid volume excess.

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1. IV fluids:

2. Juice:

3. Water:

Total intake:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infections?

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Explanation

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Correct Answer is D

Explanation

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