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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Referring a client because the unit is too busy is not an appropriate reason for a healthcare referral. Referrals should be based on the client’s specific needs and the expertise required to address those needs. Overcrowding or busyness of a unit should be managed through internal resources and staffing adjustments rather than referrals.

Choice B reason: When the care needed for the client is out of the healthcare provider’s scope of practice, a referral is necessary. This ensures that the client receives the appropriate level of care from a specialist or another provider with the required expertise. Referrals help in providing comprehensive and specialized care that the initial provider may not be equipped to deliver.

Choice C reason: Referring a client because they do not have insurance is not appropriate. Healthcare providers should assist clients in finding resources and support for their care needs, regardless of their insurance status. Referrals should be based on clinical needs, not financial or insurance considerations.

Choice D reason: Referring a client because they are late is not a valid reason for a healthcare referral. Timeliness is important, but it should not determine the need for a referral. Providers should address the reasons for lateness and work with the client to ensure they receive the necessary care.

A. Delivers a low concentration of oxygen. B. Delivers a constant rate of oxygen. C. Delivers a high concentration of oxygen. D. Delivers a constant flow of a specific concentration of oxygen.

Correct Answer is D

Explanation

Choice A Reason:

“Delivers a low concentration of oxygen” is incorrect because a nasal cannula can deliver varying concentrations of oxygen depending on the flow rate set by the healthcare provider. The concentration can range from low to moderate, typically between 24% to 44%.

Choice B Reason:

“Delivers a constant rate of oxygen” is partially correct but not entirely accurate. While the flow rate can be constant, the key aspect is the specific concentration of oxygen delivered, which is more relevant to the client’s understanding.

Choice C Reason:

“Delivers a high concentration of oxygen” is incorrect because nasal cannulas are generally used for low to moderate oxygen delivery. High concentrations of oxygen are typically delivered through other devices like non-rebreather masks or high-flow nasal cannulas.

Choice D Reason:

“Delivers a constant flow of a specific concentration of oxygen” is correct. This explanation accurately describes how a nasal cannula works. It provides a continuous flow of oxygen at a specific concentration, which is adjusted based on the client’s needs and the healthcare provider’s prescription.

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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?

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