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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"]

  1. 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

  2. Antibiotic Infusion Intake:

    • Antibiotic Solution: 25 mL

  3. 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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Related Questions

Correct Answer is A

Explanation

The correct answer is choice A. Lower the patient back to the side of the bed, pivot her back into the bed, and assess the patient's vital signs. When a patient reports feeling faint while attempting to stand, it is important to take immediate action to prevent a fall and ensure patient safety. Lowering the patient back to the bed will help prevent injury in case of a fall. Then, the nurse should pivot the patient back into the bed slowly and safely. Once the patient is lying down, assess the vital signs, particularly the blood pressure and heart rate, to ensure that the patient is stable. This information can help the nurse determine if the patient is experiencing postural hypotension or other complications from surgery. After assessing the vital signs, the nurse can report the findings to the healthcare provider and implement appropriate interventions to help prevent future episodes of fainting.

Correct Answer is D

Explanation

A. Letting the certified nursing assistant change a sterile wound dressing – Changing a sterile wound dressing is not within the scope of practice for a Certified Nursing Assistant (CNA).

B. Having the LPN complete the initial admission assessment – Initial assessments are typically within the RN's scope of practice. LPNs can assist with ongoing assessments, but the RN should handle the first comprehensive admission assessment.

C. Allowing certified nursing assistant to place an IV – CNAs are not trained or licensed to place IVs; this task requires at least an LPN or RN, depending on local regulations.

D. Asking LPN to pass morning PO blood pressure med to client.This represents proper delegation because passing oral medications, including blood pressure medications, is within the scope of practice for a Licensed Practical Nurse (LPN).

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