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.

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Free Nursing Study Resources

Correct Answer is ["C","D","E"]

Explanation

Use of blankets, pillows, and stuﬀed animals in the crib: It is important to educate parents about the risk of suﬀocation associated with soft objects in the crib. Infants should always sleep on their back in a crib with a firm matress and no loose bedding or soft objects.
Correct placement of car seats: Properly installed car seats can help prevent serious injury or death in the event of a car accident. It is important to teach parents how to properly install car seats and use them correctly.
Never leaving infant unatended in the bathtub: Drowning is a leading cause of death in young children, and infants can drown in just a few inches of water. It is important to remind parents to never leave their infant unatended in the bathtub, even for a moment.

Therefore, options c, d, and e are the most important topics to include when discussing safety with parents of infants. Options a and b may be important topics to discuss with older children, but they are not relevant to infants.

A. Put a hat in the toilet to collect proper output. B. Assess your patient’s lower extremities and lungs for ﬂuid retention. C. Educate her on the importance of writing down all ﬂuids she is drinking. D. Document the numbers anyway, there is a probable error with the intake number.

Correct Answer is B

Explanation

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

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to discuss safety with a group of parents of infants. When planning the program, which topics would be most important to include: (Select Al That Apply)

Correct Answer is ["C","D","E"]

Explanation

Correct Answer is B

Explanation

A patient with congestive heart failure is at risk of excess ﬂuid volume. Which intervention will best determine if the patient is beginning to have excess ﬂuid volume?

The nurse is caring for a client who recently had surgery on her left hip. What should be the priority teaching for the patient after surgery to prevent complications?

Patient MK is admited with Atrial Fibrillation an irregular heart rhythm. She is also complaining of muscle cramps to her legs and that she started a new diuretic last week. What lab value are you most likely to find on her Complete Metabolic Panel?

The poison control nurse receives a call from the caregiver of a young school age child who may have ingested a poisonous substance. Which is the priority response by the nurse?

The nurse is caring for a client who requires IV ﬂuids. which IV ﬂuid type would be considered a hypertonic solution?

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.

A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse?

KO is admitted with severe dehydration and electrolyte unbalances. What assessment findings are you most likely to ﬁnd initially before ﬂuid balance reaches homeostasis?