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 ["125"]

Explanation

To calculate the rate at which the IV pump should be set to deliver the prescribed volume of intravenous fluids,

Divide the total volume of fluids (3,000 mL) by the number of hours over which they are to be administered (24 hours). This calculation gives you 125 mL/hr.

Therefore, the nurse should set the IV pump to deliver 125 mL of fluid per hour to meet the 24-hour requirement.

A. Locate the middle third of the anterior thigh between the greater trochanter of the femur and the lateral femoral condyle. B. Place one finger across the acromion process and measure 3 fingerbreadths below to the midpoint and center of the lateral aspect of the upper arm. C. Find the center of the anterior aspect of the thigh. D. Locate the center of the arm between the elbow and the shoulder.

Correct Answer is B

Explanation

B. This method is recommended because the deltoid muscle is a large, rounded, triangular muscle that covers the shoulder joint.

A. This description is for locating the vastus lateralis muscle, which is commonly used for intramuscular injections in infants and young children, not adults.

C. This technique is used for locating the rectus femoris muscle, another site for intramuscular injections in infants and young children, not adults.

D. This location is too low, which could miss the muscle tissue and reduce the effectiveness of the vaccine.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with care of a client who has a prescription for 3,000 mL of intravenous fluids over the next 24 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round to the nearest whole number)

Correct Answer is ["125"]

Explanation

A nurse is preparing to administer the hepatitis B vaccine to a client. Which of the following techniques should the nurse use to locate the deltoid muscle?

Correct Answer is B

Explanation

A nurse is preparing to administer morphine 15 mg subcutaneously. The amount available is morphine injection 10 mg/mL. How many mL should the nurse administer? (Round to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is preparing to administer a subcutaneous injection to a client. Which of the following actions should the nurse plan to take?

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A nurse is caring for an 8-month-old infant who is receiving intravenous (IV) fluids via a 24-gauge catheter. Which of the following statements by the client's mother indicates that the nurse should check the site for signs of infiltration?

A nurse is caring for an older adult client. The client has an increased risk for dehydration due to which of the following physiological changes that can occur with aging?