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The nurse is calculating the output of a client at the end of the shift. The nurse notes the following: the client voided 400 mL at 1100 and 350 at 1415. The chest tube was previously marked at 155 mL and is now 175 mL. The nasogastric tube has 575 mL in the drainage container and the Jackson Pratt drain had 25 mL emptied from it. How many ml's should the nurse record as output for the shift
Answer and Explanation

The Correct Answer is ["1370"]

To calculate total output, we sum all recorded outputs:

  • Urine output:
    • 400 mL + 350 mL = 750 mL
  • Chest tube drainage:
    • 175 mL (current) - 155 mL (previous) = 20 mL
  • Nasogastric tube drainage: 575 mL
  • Jackson-Pratt drain output: 25 mL

Total Output = 750 + 20 + 575 + 25 = 1,370 mL

Correct Answer: 1,370 mL


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Related Questions

Correct Answer is C

Explanation

A. Administer supplemental oxygen: Hypokalemia primarily affects cardiac and neuromuscular function, not oxygenation. Oxygen may be needed if dysrhythmias develop but is not the highest priority.

B. Seizure precautions: While severe hypokalemia can cause muscle weakness, seizures are not the primary concern. Cardiac effects take priority.

C. Cardiac monitoring: A potassium level of 2.2 mEq/L is critically low, increasing the risk of life-threatening cardiac arrhythmias. Continuous cardiac monitoring helps detect dangerous dysrhythmias like ventricular tachycardia.

D. Initiating a fluid restriction: Fluid restriction is more relevant for hyperkalemia or fluid overload, not hypokalemia.

Correct Answer is B

Explanation

A. Assess the fistula with a large bore needle: Large bore needles are used during dialysis sessions, not for routine assessment. Inappropriate needling can damage the fistula.

B. Auscultate the fistula site for a bruit: A functional AV fistula should have a palpable thrill (vibration) and an audible bruit (whooshing sound) when auscultated with a stethoscope. These findings confirm adequate blood flow and patency.

C. Measure the blood pressure in the affected arm: Blood pressure measurements should never be taken on the fistula arm to prevent compression and potential fistula failure.

D. Assess the rate and quality of the radial pulse on the affected arm: The radial pulse does not accurately assess AV fistula patency; the focus should be on the thrill and bruit.

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