A nurse is managing a patient's fluids and outputs over a shift. Here are the details:

0700: The nurse starts an IV of 0.45% Normal saline infusing at 100 mL/hr.

0900: The patient has coffee-ground emesis (vomit) measuring 300 mL.

1000: The nurse stops the IV of 0.45% Normal saline to administer an IV antibiotic. The antibiotic administered is Kefzol 1 g in 25 mL of D5W over 30 minutes.

1030: The antibiotic infusion stops, and the nurse resumes the IV fluid of 0.45% Normal saline at 100 mL/hr.

1100: The physician orders the insertion of an NG tube and intermittent suction. The nurse inserts the NG tube and connects it to intermittent suction.

1530: The patient voids another 350 mL and 200 mL. The nurse checks the NG tube canister and records the output for the shift as 300 mL.

Calculate the patient's total intake from 0700 to 1530.

Answer and Explanation

The Correct Answer is ["725"]

IV Fluid Intake:
- From 0700 to 0900: 2 hours × 100 mL/hr = 200 mL
- From 1030 to 1530: 5 hours × 100 mL/hr = 500 mL
- Total IV Fluid Intake: 200 mL + 500 mL = 700 mL
Antibiotic Infusion Intake:
- Antibiotic Solution: 25 mL
Total Intake Calculation:
- IV Fluid Intake: 700 mL
- Antibiotic Infusion: 25 mL
- Total Intake: 700 mL + 25 mL = 725 mL

Answer: The total intake for the patient from 0700 to 1530 is 725 mL.

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Correct Answer is B

Explanation

The correct answer is choice B: Contact Precautions. Clostridium difficile (C-diff) is a bacterium that can cause severe diarrhea and other gastrointestinal problems. It is highly contagious and spreads through contact with contaminated surfaces or objects. Therefore, it is necessary to apply Contact Precautions for patients with C-diff to prevent the transmission of the infection. Contact Precautions involve wearing gloves and gowns when entering the patient's room and disposing of contaminated items properly. Additionally, hand hygiene is critical to preventing the spread of C-diff.

A. Right side B. High Fowler's position C. Supine, with feet flat D. Low Fowler's position E. Low Fowler's position

Correct Answer is B

Explanation

The correct answer is choice B, High Fowler's position. The High Fowler's position is the optimal position for nasogastric tube insertion as it allows for easy visualization and access to the nasal cavity, pharynx, and esophagus. The client should be in a semi-sitting position with the head of the bed elevated to at least 45-60 degrees. This position allows for better visualization and easier passage of the nasogastric tube through the nasal passages and into the esophagus. The other positions listed do not provide the optimal positioning for nasogastric tube insertion.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A new patient is admitted to a medical unit with Clostridium difficile (C-diff). Which type of precautions or isolation should the nurse apply for this patient?

Correct Answer is B

Explanation

The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should place the client in which position for insertion?

Correct Answer is B

Explanation

A nurse is using the SOAP documentation format to chart on their patient in a systematic and organized way. When using SOAP, what sections would be present in the charting? Select all that apply.

A nurse is teaching a preoperative patient how to use an incentive spirometer. Which instruction should be included in the education to the patient?

A client is scheduled for a routine physical assessment at the neighborhood clinic. What should the nurse do when physically assessing the client's oxygenation status? Select all that apply.

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