A nurse is evaluating the 24-hr 1&O records of several clients. Which of the following client findings indicates an acceptable fluid balance?

Intake 2,400 mL, output 2.500 mL

Intake 1,200 mL, output 700 mL

Intake 800 mL output 2,100 mL

Intake 2.500 mL output 500 mL

Answer and Explanation

The Correct Answer is A

A. This indicates a slight positive fluid balance (+100 mL), meaning the client has taken in slightly more fluids than they have excreted. This could be acceptable depending on the client's clinical condition and fluid status.

B. This indicates a negative fluid balance (-500 mL), suggesting the client has excreted more fluids than they have taken in. In some situations, such as in patients with certain conditions like edema, a negative balance might be intended.

C. This indicates a significant negative fluid balance (-1,300 mL), where the client has excreted much more fluid than they have taken in. This could indicate dehydration or fluid loss that needs to be addressed promptly.

D. This indicates a significant positive fluid balance (+2,000 mL), where the client has taken in much more fluid than they have excreted. This could indicate fluid retention, which might be acceptable in certain clinical conditions but could be problematic in others, such as in patients with congestive heart failure.

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Correct Answer is B

Explanation

B. Sharps containers should be replaced when they are 3/4 full to prevent overfilling, which could increase the risk of needlesticks when trying to dispose of sharps. Ensuring sharps containers are not overfilled helps maintain a safe environment by reducing the risk of accidental puncture injuries during disposal.

A. Used razors should be disposed of in puncture-resistant sharps containers, not in regular wastebaskets. Sharps containers are specifically designed to safely contain sharp objects to prevent accidental injuries.

C. Using two hands to recap a needle is unsafe and increases the risk of accidental needlestick injuries. It's important to educate healthcare workers to avoid recapping needles whenever possible.

D. Breaking needles before disposal is unsafe and increases the risk of injury. Needles should be disposed of intact in a puncture-resistant sharps container.

A. Cleanse the injection site with a circular motion. B. Don sterile gloves prior to the injection. C. Use the dominant hand to pinch the client's skin D. Inject the medication at a 15° angle to the client's skin

Correct Answer is A

Explanation

A. Cleansing the injection site is important to reduce the risk of infection.

B. Sterile gloves are not typically required for administering subcutaneous injections unless there is a specific indication, such as when dealing with a client who has a compromised immune system or if there is potential for exposure to bodily fluids.

C. Pinching the skin can help in creating a fold where the needle can be inserted. However, there is no standard recommendation on which hand should be used.

D. Subcutaneous injections are typically administered at a 45-degree or 90-degree angle to the client's skin, depending on the amount of subcutaneous tissue present.

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A nurse is evaluating the 24-hr 1&O records of several clients. Which of the following client findings indicates an acceptable fluid balance?

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