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
Related Questions
Correct Answer is B
Explanation
The nurse's priority finding in this case would be a change in appearance of a mole on the shoulder. Changes in the appearance of moles can be an indication of skin cancer or melanoma, which is a serious and potentially life-threatening condition. It is important for the nurse to assess the mole further and report any concerning changes to the healthcare provider for appropriate evaluation and management. The other findings, such as skin tags, a flat discolored area of skin, or atrophic fingers, may require further assessment and interventions, but they are not as immediately concerning as a potential change in a mole that could indicate skin cancer.
Correct Answer is C
Explanation
A. Change the tubing set every 72 hr:
Enteral feeding sets should generally be changed every 24 hours to reduce the risk of bacterial contamination.
B. Heat the formula to 40.5° C (105° F):
Enteral formula should be administered at room temperature. Heating it can alter the composition and pose a burn risk to the gastrointestinal mucosa.
C. Aspirate residual volume every 4 hr:
This is recommended to assess tolerance to the feeding and prevent complications like aspiration. Holding feedings may be considered based on facility policy if residuals are high.
D. Flush the tubing with 10 mL of water every 2 hr:
While flushing is necessary to maintain patency, the typical flush is 30 mL every 4 hr (or before and after medications/feedings), unless otherwise specified.
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