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","C","D","E"]
Explanation
Seizures can sometimes lead to decreased oxygen levels, and having supplemental oxygen readily available can help ensure the client's oxygenation during and after a seizure.
Seizures can sometimes cause excessive saliva or vomit, which may lead to airway obstruction. Having oral suction equipment available allows the nurse to quickly clear the airway if necessary.
In some cases, seizures can cause the client's airway to become compromised due to tongue biting or other factors. Having an oral airway available allows the nurse to maintain an open airway during a seizure and prevent any potential airway obstruction.
Hypoglycemia may lead to seizures and therefore blood glucose monitoring is important.
Limb restraints are not recommended as routine seizure precautions unless specifically ordered by the healthcare provider due to safety concerns or risk of self-injury during seizures.
Restraints should only be used as a last resort if other interventions have failed and there is a significant risk to the client's safety.
Correct Answer is C
Explanation
During the alarm reaction stage of the general adaptation syndrome (GAS), the body's initial response to stress occurs. This stage is characterized by the activation of the body's
fight-or-flight response. The nurse should identify that the manifestation that occurs during the alarm reaction stage is dilated pupils.
The alarm reaction stage is the body's immediate response to a stressor, where it mobilizes its resources to cope with the perceived threat. During this stage, the sympathetic nervous system is activated, resulting in various physiological changes to prepare the body for action. Dilated pupils are one of the responses caused by the sympathetic nervous system activation. This physiological change enhances visual acuity and allows for better peripheral vision, which can be beneficial in assessing the environment for potential threats.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today