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A nurse is calculating the output of a client at the end of the shift.
The nurse notes the following: the client voided 400 mL at 1100 and 350 mL at 1430.
The closed chest drainage system was previously marked at 155 mL and is now at 175 mL. The NG tube has 575 mL in the drainage container, and 25 mL is emptied out of the Jackson-Pratt drainage tube.
How many mL should the nurse record in the medical record as the client's output?

Answer and Explanation

The Correct Answer is ["1370"]

To calculate the total output for the client, we need to add up all the individual outputs:

The client voided 400 mL at 1100.
The client voided 350 mL at 1430.
The closed chest drainage system increased from 155 mL to 175 mL, which is an increase of 20 mL.
The NG tube has 575 mL in the drainage container.
The Jackson-Pratt drainage tube has 25 mL.

Adding all these amounts together, the total output that the nurse should record in the medical record is 1370 mL.

Here’s the calculation:

400 mL + 350 mL + (175 mL - 155 mL) + 575 mL + 25 mL = 1370 mL400mL+350mL+(175mL−155mL)+575mL+25mL=1370mL

So, the nurse should record a total output of 1370 mL in the medical record for the client.

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Correct Answer is A

Explanation

Choice A rationale:
Candidiasis, also known as thrush, is a fungal infection caused by Candida albicans. It commonly affects the mouth, causing white patches on the tongue, inner cheeks, gums, or tonsils.
Individuals with AIDS often have weakened immune systems due to a decreased CD4 T-cell count. This makes them more susceptible to opportunistic infections like candidiasis.
The fungal infection can spread to the esophagus, causing difficulty swallowing, or even to the bloodstream, leading to more serious complications.
Choice B rationale:
Xerostomia refers to dry mouth. It can be caused by various factors, including medications, salivary gland dysfunction, or radiation therapy. While it can occur in individuals with AIDS, it's not directly linked to a decreased CD4 T-cell count.
Choice C rationale:
Halitosis, or bad breath, can have multiple causes, including poor oral hygiene, gum disease, or digestive issues. It's not specifically associated with AIDS or a decreased CD4 T-cell count.
Choice D rationale:
Gingivitis is inflammation of the gums, often caused by plaque buildup. It's a common condition, but it's not directly linked to AIDS or a decreased CD4 T-cell count.

A. Hold the client's arms and legs from moving B. Place the client back in bed C. Place the client on his side D. Insert a tongue blade in the client's mouth

Correct Answer is C

Explanation

Choice A rationale:
Holding the client's arms and legs from moving during a seizure can actually cause injury to the client or the nurse. The forceful muscle contractions that occur during a seizure can cause bones to break or joints to dislocate. Additionally, trying to restrain the client can increase their agitation and make the seizure worse.

Choice B rationale:
Placing the client back in bed during a seizure is not safe. The client could fall out of bed and injure themselves. It is also important to allow the client to have space to move freely during the seizure to prevent injury.

Choice C rationale:

Placing the client on their side is the safest position for a client who is having a seizure. This position helps to protect the airway and prevent aspiration. It also allows any fluids or secretions to drain out of the mouth, which can help prevent choking.

Choice D rationale:
Inserting a tongue blade into the client's mouth during a seizure is not recommended. It is a common misconception that people can swallow their tongue during a seizure. This is not possible. Inserting a tongue blade can actually cause more harm than good. It can break teeth, damage the mouth, or even block the airway.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4 T-cell count. The nurse should recognize that the client is at risk for developing which of the following infectious oral conditions?

Correct Answer is A

Explanation

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

When planning care for a patient diagnosed with fibromyalgia, the nurse addresses the potential problem of activity intolerance. What should the nurse recommend to the patient to most effectively address this problem?

A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE). The nurse should recognize the need for further teaching when the client identifies which of the following as a factor that can exacerbate SLE?

Which of the following is the most reliable early indicator of infection in a client with low WBC?

A client comes to the clinic with a complaint of pain in the right great toe and is eventually diagnosed with gout. When planning teaching for this client, what management technique should the nurse emphasize?

A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen?

The client tells the nurse, "I am about to have a seizure." Which of the actions should the nurse implement? (Select all that apply)

A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching?

What intervention should the nurse identify as a priority for a client with a nursing diagnosis of ineffective airway clearance related to HIV-related pneumonia?