At the end of shift, you are calculating intake and output on your pat lent who was admited for a non- emergent gall bladder removal. She is alert and oriented and able to recall the amount of ﬂuid she has drank all day. You can calculate the amount of IV ﬂuids administered. Her intake is 2500ml and her output is 1200ml from a catheter bag. You realize she is not excreting enough urine me for water she is taking in. What is the most appropriate next step to determine if she is retaining water?

Put a hat in the toilet to collect proper output.

Assess your patient’s lower extremities and lungs for ﬂuid retention.

Educate her on the importance of writing down all ﬂuids she is drinking.

Document the numbers anyway, there is a probable error with the intake number.

Answer and Explanation

The Correct Answer is B

. Assess your patient’s lower extremities and lungs for ﬂuid retention.

If a patient’s intake is 2500ml and her output is 1200ml from a catheter bag, and you are concerned that she may not be excreting enough urine for the amount of water she is taking in, the most appropriate next step would be to assess her lower extremities and lungs for ﬂuid retention. This can help determine if the patient is retaining water and if further intervention is necessary.

Nursing Test Bank

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Correct Answer is D

Explanation

This outcome is the most appropriate because smoking can worsen COPD and lead to further respiratory complications, while oxygen is often used to help patients with COPD breathe more easily. Smoking while wearing oxygen can be very dangerous and increases the risk of fire and explosion. Therefore, the best expected outcome is for the patient to completely avoid smoking while wearing oxygen.

Option a is not a recommended solution since vaping may also worsen COPD symptoms and there is limited evidence of its safety in people with respiratory conditions. Option b is a good outcome, but it may not be achievable in such a short time frame. Option c is not an ideal outcome as even a few cigaretes can cause harm to the respiratory system, exacerbate symptoms, and slow down the healing process.

A. An E KG is a painless diagnostic study. We will put stickers on your body and atach wires to assess your heart rhythm. B. This will only take a minute there is nothing to fear, we do them all the time. C. I've performed many ECGs over the years and have become an expert in doing them. D. We have many children that come to the ER and receive an ECG. they say they are painless.

Correct Answer is A

Explanation

This response provides the patient with accurate and reassuring information about the EKG procedure. It explains that the test is painless and describes what will happen during the test. The other responses do not provide as much information or reassurance to the patient.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

MK is admited with COPD exacerbation. Your nursing care plan reads Impaired Gas Exchange, related to smoking 1 PPD of cigaretes. AED pursed lip breathing shortness of breath. Which is the best expected outcome for this diagnosis.

Correct Answer is D

Explanation

Your patient is ordered an EKG upon admission to the hospital. She is very scared and states she has never had one of these diagnostic tests before. Which answer is most appropriate by the nurse regarding EKG.

Correct Answer is A

Explanation

A patient presents to the Emergency Room with swollen legs and shortness of breath. He tells you that he has a history of heart failure which causes the ﬂuid to build up m his legs and lungs. When you listen to his lung sounds you are most likely to hear which type of breathing sounds?

A client with renal disease requires IV ﬂuids. It is important for the nurse to:

Respiratory Therapy has an order to perform chest physiotherapy on your patient who has COPD. Your patient’s lung sounds are diminished, but free of secretions. What should the proper response be from the nurse to the respiratory therapist:

A patient newly diagnosed with heart failure understands that heart failure means there is a lack of sufficient blood supply to the patient's tissue throughout the body tells you that the is responsible for pumping blood from the hear t to the lest of the body.

A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response?

You are setting up a room for your patient that has a new tracheostomy. Select all of the equipment you need bring with to ensure patient is safe should the tracheostomy become dislodged: