In continuous bladder irrigation (CBI) if 200 mL of sterile saline solution is instilled into the bladder and 300 mL of urine and solution are drained out, how much true urine output is calculated?

150 ml

100 mL

200 ml

50 mL

Answer and Explanation

The Correct Answer is B

A. 150 mL: This calculation is incorrect because the amount of fluid drained includes both the saline solution and the urine. The true urine output is the difference between what was drained and what was instilled.

B. 100 mL: The true urine output is calculated by subtracting the amount of saline instilled from the total output. In this case, 300 mL was drained, and 200 mL was saline. Therefore, 300 mL - 200 mL = 100 mL of true urine output.

C. 200 mL: This would be the amount of saline instilled, not the urine output. The true urine output needs to account for the saline volume that was used in the irrigation process.

D. 50 mL: The correct calculation subtracts the 200 mL of saline from the total 300 mL drained, which gives 100 mL of true urine output, not 50mL.

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Correct Answer is C

Explanation

A. Measuring urine output: While urine output is important to monitor, it is not the highest priority in this situation. The main concern with a low platelet count is the risk of bleeding, so assessing for signs of internal bleeding is more critical.

B. Maintaining strict bedrest: Strict bedrest may be necessary for preventing falls and injury, but it is not the highest priority. The immediate concern with a platelet count of 47,000 is the potential for bleeding, which requires close monitoring for signs of bleeding.

C. Assessing for stool occult blood: A platelet count of 47,000 puts the client at risk for bleeding, including gastrointestinal bleeding. Assessing for occult blood in the stool is crucial, as it can indicate internal bleeding, which requires prompt intervention.

D. Drawing an ABG: Drawing an arterial blood gas (ABG) would not directly address the risk of bleeding related to a low platelet count. The priority is assessing for and preventing potential bleeding complications.

A. respiratory acidosis B. respiratory alkalosis. C. Metabolic alkalosis, D. metabolic acidosis.

Correct Answer is B

Explanation

A. Respiratory acidosis: Respiratory acidosis would be characterized by a low pH and high PaCO2. In this case, the pH is elevated (7.51), and PaCO2 is low (28 mmHg), which indicates respiratory alkalosis, not acidosis.

B. Respiratory alkalosis: Respiratory alkalosis occurs when there is a decrease in PaCO2 (below 35 mmHg) due to hyperventilation. The low PaCO2 (28 mmHg) and elevated pH (7.51) are indicative of respiratory alkalosis, where the body is losing too much CO2.

C. Metabolic alkalosis: While the pH is elevated, the bicarbonate (HCO3) level is within normal range (24 mEq/L), which suggests that the cause of the alkalosis is not metabolic in nature. Respiratory alkalosis is the more appropriate interpretation.

D. Metabolic acidosis: Metabolic acidosis would be associated with a low pH and a low bicarbonate (HCO3) level. In this case, the pH is elevated and HCO3 is normal, so metabolic acidosis is not the correct interpretation.

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In continuous bladder irrigation (CBI) if 200 mL of sterile saline solution is instilled into the bladder and 300 mL of urine and solution are drained out, how much true urine output is calculated?

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Naxlex Comprehensive Predictor Exams

A client's lab report shows a platelet count of 47,000. The normal range for platelets is between 150,000 and 450,000. Which of the following nursing interventions is the nurse's highest priority?

Correct Answer is C

Explanation

The client's arterial blood gases reveal the following results: pH 7.51. Pa02 80 mmHg, PaCO2 28 mmHg. HCO3 24 mEq/L 02 saturation 92%. The nurse interprets this blood gas result as: PH7.35-7.45 PCO2 35-45mm Hg HCO3 22-26 m/l Sa02 95-100% PaO2 80-100mm Hg

Correct Answer is B

Explanation

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