After reviewing the client's intake and output record for the last eight hours, the nurse calculates the client's current fluid balance as how many mL? (Enter numeric value only).
- 0730-8 oz of orange juice, hard boiled egg, and toast
- 0830-voided 150 ml
- 1200-1 cup of soup, tuna sandwich, and 1/2 cup of apple juice
- 1300 vomitus of 100 mL
- 1400 voided 250 mL and drank one 12 oz can of soft drink
The Correct Answer is ["455"]
-
Intake:
- 8 oz of orange juice = 240 mL
- 1 cup of soup = 240 mL
- 1/2 cup of apple juice = 120 mL
- 12 oz can of soft drink = 355 mL
- Total intake = 240 + 240 + 120 + 355 = 955 mL
-
Output:
- Voided 150 mL
- Vomitus 100 mL
- Voided 250 mL
- Total output = 150 + 100 + 250 = 500 mL
-
Fluid Balance:
- Fluid balance = Intake - Output = 955 - 500 = 455 mL
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A
Bananas are incorrect. While bananas contain some nutrients, they are not significant sources of vitamin D, calcium, or phosphate, which are key nutrients for preventing rickets.
Choice B
Apple juice is incorrect. Apple juice is not a significant source of vitamin D, calcium, or phosphate. It may contain some vitamins and minerals, but it is not a primary food source for preventing rickets.
Choice C
Oranges are incorrect. Like bananas and apple juice, oranges are not significant sources of vitamin D, calcium, or phosphate. While they contain vitamin C, which is important for overall health, they are not the best dietary source for preventing rickets.
Choice D
Fortified milk is correct. Rickets is a condition primarily caused by a deficiency of vitamin D, calcium, or phosphate. Vitamin D is crucial for the proper absorption of calcium and phosphorus in the body, which are essential for bone health and development. Fortified milk is an excellent dietary source for preventing rickets because it is often enriched with vitamin D and calcium, both of which are important for bone mineralization and growth.
Correct Answer is A
Explanation
Choice A
Sending fluid specimen to the lab should be implemented. Cloudy green fluid aspirated from a nasogastric tube (NGT) can indicate that the tube is in the wrong place, likely in the respiratory tract (trachea) instead of the gastrointestinal tract (stomach). The green colour suggests the presence of bile, which is normally found in the stomach but not in the respiratory tract. This is a serious situation that requires immediate attention.
The most appropriate intervention in this case is to send the fluid specimen to the lab for analysis. This is important for confirmation of the content and to guide further steps. The nurse should also consult the healthcare provider to determine the appropriate course of action, which might involve removing and reinserting the NGT correctly.
Choice B
Withdrawing the NGT and reinsert should not be implemented. If the NGT is in the wrong place, reinserting it without further assessment could worsen the situation. The nurse should not reinsert the NGT until the correct placement is confirmed.
Choice C
Connecting the NGT to wall suction should not be implemented. Connecting the NGT to wall suction without verifying its placement could cause harm, especially if the tube is in the respiratory tract.
Choice D
Determine pH value of specimen should not be implemented. While assessing the pH of aspirated fluid can help confirm the location of the NGT, sending the specimen to the lab for analysis is a more comprehensive action in this situation, as it allows for more detailed examination and guidance for appropriate next steps.
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