A nurse is reviewing a client's intake and output and notes the following: 0.9% sodium chloride 600 mL IV infusion, cefazolin 250 mg in dextrose 5% in water 100 mL. Intermittent IV bolus, 200 mL emesis, 40 mL voided urine, and 20 mL urine from straight catheterization. The nurse should record the client's net fluid intake as how many mL? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
The Correct Answer is ["440"]
To calculate the client's net fluid intake, we need to subtract the output (emesis and urine) from
the intake (IV infusion and IV bolus). Intake:
- 0.9% sodium chloride IV infusion: 600 mL
- Cefazolin in dextrose 5% in water IV bolus: 100 mL Output:
- Emesis: 200 mL
- Voided urine: 40 mL
- Urine from straight catheterization: 20 mL Net fluid intake = Intake - Output
Net fluid intake = (600 mL + 100 mL) - (200 mL + 40 mL + 20 mL) Net fluid intake = 700 mL - 260 mL
Net fluid intake = 440 mL
Therefore, the nurse should record the client's net fluid intake as 440 mL.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is A
Explanation
The tracheostomy ties should be secure enough to keep the tracheostomy tube in place but loose enough to allow for proper circulation and prevent skin breakdown. Allowing one finger to fit snugly underneath ensures that the ties are not too tight, which can compromise blood flow
Correct Answer is C
Explanation
When administering medications via an NG tube to a client who is receiving a continuous tube feeding, it is important to flush the tube with water before and after each medication to ensure that the medication is delivered and to prevent any medication from remaining in the tube and causing a blockage. Flushing the tube with 5 mL of sterile water prior to administration will help clear the tube and ensure that the medication is delivered effectively.
Mixing the medications together in a single syringe or combining the medications with the formula in the feeding bag can lead to medication interactions or decreased medication efficacy. Diluting each crushed medication with sterile water may not be necessary, as long as the medication is crushed into a fine powder and flushed properly before and after administration
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