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?
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale:
Antinuclear antibody (ANA) titer is a blood test that detects the presence of antinuclear antibodies, which are autoantibodies that target the body's own tissues. These antibodies are often present in people with autoimmune diseases, including rheumatoid arthritis.
While a positive ANA test does not definitively diagnose rheumatoid arthritis, it can support a diagnosis when considered alongside other clinical findings and laboratory tests.
Choice B rationale:
Blood urea nitrogen (BUN) is a blood test that measures the amount of urea nitrogen in the blood. Urea nitrogen is a waste product that is produced when the body breaks down proteins.
BUN levels can be elevated in people with kidney disease, dehydration, or certain other medical conditions. However, BUN is not specifically used to diagnose rheumatoid arthritis.
Choice C rationale:
Urinalysis is a test that examines the urine for various substances, including cells, bacteria, and chemicals.
It can be used to diagnose a variety of conditions, including urinary tract infections, kidney disease, and diabetes. However, urinalysis is not typically used to diagnose rheumatoid arthritis.
Choice D rationale:
Erythrocyte sedimentation rate (ESR) is a blood test that measures how quickly red blood cells settle at the bottom of a test tube.
A high ESR can indicate inflammation in the body.
ESR is often elevated in people with rheumatoid arthritis, as it is a marker of inflammation.
Choice E rationale:
White blood cell count (WBC) is a blood test that measures the number of white blood cells in the blood. White blood cells are part of the immune system and help fight infection.
A high WBC count can indicate an infection or inflammation.
WBC count can be elevated in people with rheumatoid arthritis, as it is a marker of inflammation.
Correct Answer is C
Explanation
Choice A rationale:
Restricting weight-bearing on the affected foot may provide some temporary relief from pain during an acute gout attack. However, it is not a long-term management strategy and can lead to muscle weakness and joint stiffness. It's important to gradually resume weight-bearing activities as tolerated to maintain joint function.
Choice B rationale:
Adequate fluid intake is essential for overall health and can help to flush out uric acid from the body. However, 8 liters per day is an excessive amount of fluid and could lead to electrolyte imbalances and other health problems. A more appropriate recommendation for a client with gout would be to aim for a fluid intake of 2-3 liters per day, unless otherwise advised by a healthcare provider.
Choice C rationale:
Restricting consumption of foods high in purines is a key management strategy for gout. Purines are substances found in certain foods that break down into uric acid in the body. High levels of uric acid can lead to the formation of urate crystals, which deposit in joints and cause inflammation and pain. Examples of foods high in purines include organ meats, red meat, seafood, and some types of beans and lentils.
Choice D rationale:
Calcium supplements have not been shown to be effective in the management of gout. In fact, some studies have suggested that calcium supplements may even increase the risk of gout attacks.
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