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?

Choice A rationale

Administering oxygen at 6 liters per minute via nasal cannula risks hypercapnia in a client with emphysema due to impaired CO2 elimination. Oxygen should be titrated to maintain safe saturation levels, usually 88–92%.

Choice B rationale

Ipratropium is a bronchodilator that safely alleviates airway constriction in emphysema without systemic cardiovascular effects, making it suitable for a client with coronary artery disease and chronic obstructive pulmonary conditions.

Choice C rationale

Propranolol is contraindicated in emphysema due to its beta-blocking effects, which may exacerbate bronchoconstriction and reduce respiratory function, posing a significant risk to the client’s health.

Choice D rationale

Organic herbal supplements lack evidence-based safety and efficacy, especially in complex medical conditions like coronary artery disease and emphysema. They can also interact adversely with prescribed medications.

Choice A rationale

A decreased level of consciousness indicates possible intracranial hemorrhage, a complication of thrombolytic therapy. Altered mental status may result from brain bleeding disrupting normal neural function.

Choice B rationale

Elevated blood pressure and headache suggest intracranial hemorrhage, as the rise in intracranial pressure often accompanies vascular disruption and neurogenic pain.

Choice C rationale

Vomiting and persistent nausea can signal intracranial hemorrhage, as blood irritating brain tissue and increasing pressure stimulates the emetic center in the medulla.

Choice D rationale

Positive Babinski's sign is associated with upper motor neuron lesions but is not a direct indicator of thrombolytic therapy complications such as intracranial bleeding.

Choice E rationale

Fever and cardiac dysrhythmias do not directly indicate thrombolytic therapy complications. Dysrhythmias may stem from electrolyte disturbances or infections unrelated to hemorrhage.