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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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Correct Answer is A

Explanation

The correct answer is choice A: "The JP drain uses negative suction to drain fluid from the wound." The purpose of the Jackson-Pratt drain is to remove excess fluid or blood from the surgical site. This drain uses a bulb-like container that creates negative pressure or suction, which allows the fluid to be removed from the wound into the container. It is important to maintain negative pressure to ensure that the drain is functioning properly. The nurse should also instruct the client on how to monitor the drainage and how often to empty the container, and to report any changes in the amount, color, or odor of the fluid to the healthcare provider.

Correct Answer is B

Explanation

The correct answer is choice B, Use water and mild soap.

When teaching a patient about ostomy care, the nurse should instruct the patient to clean the area around the ostomy with water and mild soap. Using a whirlpool bath, alcohol-based sanitizer, or chlorhexidine or HCG is not recommended as they can irritate the skin and damage the stoma. Cleansing the ostomy area with water and mild soap is the best way to maintain the skin's integrity and prevent irritation and infection.

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