The nurse determines the total intake for a client diagnosed with acute kidney injury. The client received 650 mL of intravenous fluid, 6 ounces of water, and 8 ounces of chicken broth during the shift.
The client's urinary output for the shift is 820 mL. What is the total intake the nurse will record for this client?
1060 mL
1055 mL
1050 mL
1070 mL
The Correct Answer is D
Choice A rationale: This is not the accurate amount of fluid intake by the patient.
Choice B rationale: This is less than the total fluid intake by the patient.
Choice C rationale: This is less than the total fluid intake by the patient.
Choice D rationale: This is correct.( This is the sum of the intravenous fluid, the water, and the chicken broth, converted to milliliters: 650 + (6 x 30) + (8 x 30) = 1070.)
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: After visual inspection, the next step typically involves auscultation, which allows the nurse to listen for bowel sounds and gather information about
gastrointestinal function.
Choice B rationale: Percussion involves tapping the abdomen to assess density or abnormal masses but usually follows auscultation.
Choice C rationale: Palpation, both light and deep, follows percussion in the sequence of an abdominal examination.
Choice D rationale: Similar to light palpation, deep palpation follows auscultation and percussion in the sequence of an abdominal examination.
Correct Answer is B
Explanation
Choice A rationale: Rotating the neck to one side while observing the eyes moving to the opposite side is a procedure for testing for oculocephalic reflex or doll's eye
phenomenon, which indicates brainstem function.
Choice B rationale: This is the correct answer. Kernig's sign is a clinical sign that indicates meningitis, which is an inflammation of the membranes that cover the brain and spinal cord. To test for Kernig's sign, the nurse should flex the patient's hip to 90 degrees and then attempt to extend the knee. A positive Kernig's sign is when the patient
experiences pain in the lower back or hamstring, resists knee extension, or involuntarily flexes the opposite leg.
Choice C rationale: Stroking the lateral aspect of the sole of the patient's foot and observing for dorsiflexion of the big toe is a procedure for testing for Babinski's sign, which indicates upper motor neuron lesion or damage.
Choice D rationale: Passively flexing the patient's neck forward and observing for hip and knee flexion is a procedure for testing for Brudzinski's sign, which also indicates meningitis.
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