A nurse is calculating the intake of a client during the past 9 hours.
The client's intake includes:
- Lactated Ringer's IV at 150 mL/hr
- cefazolin 2 g IV intermittent bolus in 100 mL of 0.9% sodium chloride
- two units of packed RBCs of 275 mL and 250 mL
- two IV bolus infusions of 250 mL of 0.9% sodium chloride
- ranitidine 50 mg IV intermittent bolus in 50 mL of dextrose 5% in water.
How many mL of intake should the nurse record?
The Correct Answer is ["2525"]
Step 1 is calculate intake from lactated Ringer’s: 150 mL/hr × 9 hrs = 1350 mL.
Step 2 is calculate cefazolin intake: 100 mL × 1 dose = 100 mL.
Step 3 is calculate intake from two units of packed RBCs: 275 mL + 250 mL = 525 mL.
Step 4 is calculate intake from two IV boluses: 250 mL × 2 = 500 mL.
Step 5 is calculate intake from ranitidine infusion: 50 mL × 1 dose = 50 mL.
Step 6 is calculate total intake: 1350 mL + 100 mL + 525 mL + 500 mL + 50 mL = 2525 mL. Final calculated intake is 2525 mL.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While bleeding could indicate trauma, EEG does not detect blood presence or volume but instead evaluates electrical brain activity indicative of neuronal function.
Choice B rationale
Cerebral oxygen intake assessment requires pulse oximetry or arterial blood gas analysis rather than EEG, which monitors electrical signals, not oxygenation status.
Choice C rationale
EEG identifies abnormal brain wave patterns suggesting ongoing seizure activity, even in sedated patients, aiding in targeted interventions and preventing potential complications.
Correct Answer is D
Explanation
Choice A rationale
Scheduled voiding relies on the patient’s ability to control bladder function, which is ineffective in cases of a flaccid bladder caused by spinal cord injuries.
Choice B rationale
External catheters, such as condom catheters, are suited for patients with partial bladder control but are not appropriate for flaccid or atonic bladder management.
Choice C rationale
Indwelling urinary catheters may be used short-term but pose higher risks of urinary tract infections and are not optimal for long-term management of flaccid bladder.
Choice D rationale
Intermittent catheterization is the preferred method for managing flaccid bladder, ensuring complete bladder emptying while minimizing infection risks compared to indwelling catheters.
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