A nurse is calculating the intake of a client during the past 9 hours.
The client's intake includes:
- Lactated Ringer's IV at 150 mL/hr
- cefazolin 2 g IV intermittent bolus in 100 mL of 0.9% sodium chloride
- two units of packed RBCs of 275 mL and 250 mL
- two IV bolus infusions of 250 mL of 0.9% sodium chloride
- ranitidine 50 mg IV intermittent bolus in 50 mL of dextrose 5% in water.
How many mL of intake should the nurse record?
The Correct Answer is ["2525"]
Step 1 is calculate intake from lactated Ringer’s: 150 mL/hr × 9 hrs = 1350 mL.
Step 2 is calculate cefazolin intake: 100 mL × 1 dose = 100 mL.
Step 3 is calculate intake from two units of packed RBCs: 275 mL + 250 mL = 525 mL.
Step 4 is calculate intake from two IV boluses: 250 mL × 2 = 500 mL.
Step 5 is calculate intake from ranitidine infusion: 50 mL × 1 dose = 50 mL.
Step 6 is calculate total intake: 1350 mL + 100 mL + 525 mL + 500 mL + 50 mL = 2525 mL. Final calculated intake is 2525 mL.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Elevating the head 30-45 degrees aids in venous drainage and reduces intracranial pressure. It also prevents cerebral edema by improving cerebrospinal fluid outflow without compromising cerebral perfusion.
Choice B rationale
Serial neurological assessments help monitor for changes in intracranial pressure, enabling early intervention. They ensure timely recognition of symptoms indicating worsening pressure or neurological deterioration.
Choice C rationale
Frequent suctioning increases intracranial pressure due to stimulation of the vagus nerve, leading to coughing or gagging. It can also induce hypoxia, further exacerbating intracranial pressure.
Choice D rationale
Administering sedatives and pain medications reduces cerebral metabolic rate and sympathetic stimulation, which in turn prevents spikes in intracranial pressure. It also helps prevent agitation and discomfort in the patient.
Choice E rationale
Stimulating the patient with TV, music, lights, and family increases sensory input, which can elevate intracranial pressure. Overstimulation can cause agitation, raising intracranial pressure further.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Proper nutrition, exercise, and stress reduction enhance psychological well-being, stimulating endorphin release, which improves mood and resilience, essential for managing chronic conditions like HIV.
Choice B rationale
These factors bolster immune function by reducing cortisol levels that impair immunity, supporting T-cell activity and promoting resistance against opportunistic infections common in HIV patients.
Choice C rationale
Maintaining strength and independence aids patients in daily functioning, reducing dependency and enhancing self-efficacy, which is critical for long-term adherence to therapeutic regimens in HIV.
Choice D rationale
Preventing virus transmission requires safe practices, not lifestyle changes alone. Nutrition and exercise cannot alter transmission mechanisms like exposure to body fluids.
Choice E rationale
Eliminating HIV completely necessitates antiretroviral therapy and advancements in medical science; lifestyle modifications alone are insufficient against viral integration within host DNA.
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