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The nurse is calculating maintenance IV fluid requirements for a child who weighs 48 pounds. Using the continuous fluid maintenance formula, calculate the rate (ml/hr) the nurse will set the pump?

Round to the nearest whole number. Enter the number only, no units.

Answer and Explanation

The Correct Answer is ["64"]

To calculate the maintenance IV fluid rate for a child, we typically use the Holliday-Segar formula:

For the first 10 kg of weight: 100 ml/kg/day
For the next 10 kg of weight: 50 ml/kg/day
For any additional weight: 20 ml/kg/day

The weight of the child is 48 pounds, which is approximately 21.8 kg (since 1 pound = 0.45 kg).

Using the formula:

First 10 kg: 100 ml/kg/day = 1000 ml/day
Next 10 kg: 50 ml/kg/day = 500 ml/day
Remaining 1.8 kg: 20 ml/kg/day = 36 ml/day

Total = 1000 ml + 500 ml + 36 ml = 1536 ml/day

To find the rate in ml/hr: 1536 ml/day ÷ 24 hours/day = 64 ml/hr

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Correct Answer is C

Explanation

Choice A reason: Discontinuing the indwelling catheter is not appropriate without first assessing the cause of the low urine output.

Choice B reason: Increasing the intravenous fluid rate might be considered if the patient is dehydrated, but first, the nurse should ensure that the low urine output is not due to a mechanical issue with the catheter.

Choice C reason: Checking the catheter for patency is the most immediate and appropriate action. There could be a blockage or kink in the catheter, which might explain the low urine output.

Choice D reason: Documenting the finding is important, but it should be done after addressing the immediate concern of low urine output and confirming that the catheter is functioning properly.

A. Facilitate an early discharge. B. Discontinue oxycodone administration. C. Restrict visitor time. D. Provide breast pump.

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

Explanation

Choice A reason: Facilitating an early discharge is not appropriate in this case. Patients with PPROM require careful monitoring and management to prevent infections and other complications.

Choice B reason: Discontinuing oxycodone administration may be necessary to prevent potential adverse effects on both the patient and the baby, especially considering the patient's recent delivery and current condition.

Choice C reason: Restricting visitor time can help reduce the risk of infection, especially for a patient with PPROM and a newborn who may have a compromised immune system.

Choice D reason: Providing a breast pump is important to help the mother establish and maintain lactation, especially if the baby is premature and may have difficulty breastfeeding directly.

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The nurse is calculating maintenance IV fluid requirements for a child who weighs 48 pounds. Using the continuous fluid maintenance formula, calculate the rate (ml/hr) the nurse will set the pump? Round to the nearest whole number. Enter the number only, no units.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the urinary output of a patient 4 hours after a caesarean birth. The patient weighs 68 kg and the indwelling catheter bag measures 125 mL of urine. Which action will the nurse include in the plan of care?

Correct Answer is C

Explanation

The nurse is caring for a G4P1, 31 weeks and 2 days gestation, 41-year-old patient, with premature prolonged rupture of membranes (PPROM) 7 hours after delivery. Which interventions will the nurse include in the plan of care? Select all that apply.

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

Explanation

The nurse is calculating maintenance IV fluid requirements for a child who weighs 48 pounds. Using the continuous fluid maintenance formula, calculate the rate (ml/hr) the nurse will set the pump? Round to the nearest whole number. Enter the number only, no units.

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The nurse is calculating maintenance IV fluid requirements for a child who weighs 48 pounds. Using the continuous fluid maintenance formula, calculate the rate (ml/hr) the nurse will set the pump?

Round to the nearest whole number. Enter the number only, no units.