A client has an order for continuous bladder irrigation. What should the nurse do with the irrigation solution on the intake and output (I&O) sheet when calculating the fluid balance for this client?
Deduct it from the total urine output.
Subtract it from the intravenous flow sheet as output.
Document the intake hourly in the urine output column.
Add it to the oral intake column.
The Correct Answer is A
Choice A Reason:
When calculating the fluid balance for a client undergoing continuous bladder irrigation (CBI), the irrigation solution must be deducted from the total urine output. This is because the irrigation fluid is not part of the client’s actual urine production but is an additional fluid introduced into the bladder to prevent or remove blood clots and ensure catheter patency. By deducting the irrigation solution from the total urine output, the nurse can accurately determine the client’s true urine output and fluid balance.
Choice B Reason:
Subtracting the irrigation solution from the intravenous flow sheet as output is incorrect. The intravenous flow sheet is used to document fluids administered intravenously, not those introduced into the bladder. Therefore, this choice does not apply to the management of continuous bladder irrigation.
Choice C Reason:
Documenting the intake hourly in the urine output column is also incorrect. The urine output column should reflect the actual urine produced by the client, not the irrigation solution. Including the irrigation solution in this column would lead to an inaccurate representation of the client’s urine output and fluid balance.
Choice D Reason:
Adding the irrigation solution to the oral intake column is incorrect as well. The oral intake column is designated for fluids consumed orally by the client. The irrigation solution is introduced directly into the bladder and should not be recorded as oral intake.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Ask close-ended questions is incorrect. Close-ended questions typically elicit short, specific responses such as “yes” or “no.” While they can be useful in certain situations, they do not provide enough information to thoroughly assess a client’s mental status. Open-ended questions allow the client to express themselves more fully, providing the nurse with better insight into their cognitive function.
Choice B Reason:
Ask open-ended questions is correct. Open-ended questions encourage the client to elaborate on their thoughts and feelings, which can reveal more about their mental status. This type of questioning helps the nurse assess the client’s orientation, memory, and thought processes more effectively.
Choice C Reason:
Use directive questions is incorrect. Directive questions are more structured and guide the client towards specific answers. While they can be useful for obtaining specific information, they do not allow for a comprehensive assessment of the client’s mental status.
Choice D Reason:
Use reflective questions is incorrect. Reflective questions are used to encourage the client to think more deeply about their responses and feelings. While they can be helpful in therapeutic settings, they are not the most effective for an initial assessment of mental status.
Correct Answer is A
Explanation
Choice A Reason:
Sclera is correct. The sclera, or the white part of the eye, is a reliable site to assess for jaundice, especially in dark-skinned individuals. Jaundice causes a yellowish discoloration of the sclera due to the accumulation of bilirubin in the blood. This yellowing is often more noticeable in the sclera than in other parts of the body.
Choice B Reason:
Dorsal surface of the foot is incorrect. The dorsal surface of the foot is not a reliable site for assessing jaundice, particularly in dark-skinned individuals. The skin on the feet may not show the yellow discoloration as clearly as the sclera.
Choice C Reason:
Pinnae of the ears is incorrect. The pinnae, or outer parts of the ears, are not typically used to assess for jaundice. The skin in this area may not show the yellow discoloration as effectively as the sclera.
Choice D Reason:
Palmar surface of the hand is incorrect. While the palms can sometimes show signs of jaundice, they are not as reliable as the sclera. The yellow discoloration may be less noticeable on the palms, especially in dark-skinned individuals.
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