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 D

Explanation

A. 2+ Pitting Edema:This refers to moderate pitting edema where the indentation is approximately 4 mm and disappears within 10-15 seconds.

B. 3+ Pitting Edema:This refers to moderately severe pitting edema where the indentation is approximately 6 mm and may last longer than 1 minute but does not remain for as long as 4 minutes.

C. 1+ Non-Pitting Edema:This grade refers to mild pitting edema with a 2 mm indentation that quickly disappears within a few seconds.

D. 4+ Pitting Edema:4+ pitting edema is characterized by a very deep pit (approximately 8 mm) that may last 2-5 minutes or more. This matches the scenario where the pit is 8 mm deep and remains for 4 minutes.

A. Documenting an assessment that was not performed B. The nurse documents that the family has asked to speak to the doctor C. The nurse fails to document the doctor's verbal order for a new medication D. The nurse left their badge at home and cannot sign into the EHR E. The nurse documents blood labs were sent before the blood draw was performed

Correct Answer is ["A","E"]

Explanation

Correct answers are:

A. Documenting an assessment that was not performed

E. The nurse documents blood labs were sent before the blood draw was performed

Falsification of health records refers to deliberately misrepresenting, fabricating, or altering documentation, which could lead to severe consequences for patients and healthcare providers. In option A, documenting an assessment that was not performed is falsification of health records because it misrepresents the care provided to the patient. Similarly, in option E, documenting that blood labs were sent before the blood draw was performed is a falsification of health records because it is not an accurate representation of the actual order of events.

Options B, C, and D do not involve falsification of health records, but they may be considered documentation errors or violations of organizational policies.

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Naxlex Comprehensive Predictor Exams

A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: Pitting edema; 8-mm pit. Pit remained for 4 minutes after pressing. What grade of edema has this nurse documented?

Correct Answer is D

Explanation

Which of the following would be falsification of health records? Select all that apply.

Correct Answer is ["A","E"]

Explanation

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The nurse has assessed the client, analyzed the data, and identified constipation as a patient health problem. Which assessment cues would support constipation? Select all that apply.

Kübler-Ross defines five stages of psychosocial responses to dying and death. Which of the following statements is characteristic of the denial stage?

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The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth?

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