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A 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 mL at 1430.
The closed chest drainage system was previously marked at 155 mL and is now at 175 mL. The NG tube has 575 mL in the drainage container, and 25 mL is emptied out of the Jackson-Pratt drainage tube.
How many mL should the nurse record in the medical record as the client's output?

Answer and Explanation

The Correct Answer is ["1370"]

To calculate the total output for the client, we need to add up all the individual outputs:

The client voided 400 mL at 1100.
The client voided 350 mL at 1430.
The closed chest drainage system increased from 155 mL to 175 mL, which is an increase of 20 mL.
The NG tube has 575 mL in the drainage container.
The Jackson-Pratt drainage tube has 25 mL.

Adding all these amounts together, the total output that the nurse should record in the medical record is 1370 mL.

Here’s the calculation:

400 mL + 350 mL + (175 mL - 155 mL) + 575 mL + 25 mL = 1370 mL400mL+350mL+(175mL−155mL)+575mL+25mL=1370mL

So, the nurse should record a total output of 1370 mL in the medical record for the client.

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Free Nursing Study Resources

Correct Answer is ["A","B","E"]

Explanation

Choice A rationale:
Loosening the patient's clothing around the neck and chest promotes easier breathing during the seizure. It also prevents potential injury from constrictive clothing that could restrict movement or circulation.
Choice B rationale:
Easing the patient to the floor if they are standing helps to prevent falls and injuries that could occur due to loss of consciousness and muscle control during the seizure. It's crucial to guide the patient gently to the floor to avoid abrupt movements that could trigger or worsen the seizure.
Choice C rationale:
Restraining the patient during a seizure is not recommended as it can cause harm. Attempting to restrain a patient's movements during a seizure can lead to muscle strains, joint injuries, or even fractures. It can also increase anxiety and agitation, potentially prolonging the seizure.
Choice D rationale:
Protecting the patient's mouth with a padded tongue blade is not necessary and can even be dangerous. It was once a common practice, but it's now discouraged as it can cause oral injuries, obstruct the airway, or induce vomiting.

Choice E rationale:
Providing privacy helps to protect the patient's dignity and reduce any potential embarrassment during the seizure. It also creates a calmer and less stimulating environment, which can be beneficial in managing the seizure.

A. “Were you feeling jittery or irritable prior to the seizure?” B. “Are you feeling sleepy or very tired at this time?” C. “When did you last take your seizure medication?” D. “Do you know if you lost consciousness during the seizure?”

Correct Answer is C

Explanation

Choice A rationale:
While inquiring about pre-seizure symptoms can be informative, it's not the most crucial question at this point. The priority is to gather information about medication adherence to assess potential causes for the breakthrough seizure.

Choice B rationale:
Assessing for post-ictal fatigue is important, but it's not the most pressing question in the immediate aftermath of a seizure. Determining medication adherence takes precedence.

Choice D rationale:
Establishing whether consciousness was lost can aid in classifying seizure type, but it's not as critical as understanding medication adherence in the initial assessment.

Choice C rationale:
This question directly addresses a potential cause of the seizure. Understanding when the client last took their medication can help determine if missed or delayed doses contributed to the seizure, guide medication adjustments, and inform further seizure prevention strategies.

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Naxlex Comprehensive Predictor Exams

The client tells the nurse, "I am about to have a seizure." Which of the actions should the nurse implement? (Select all that apply)

Correct Answer is ["A","B","E"]

Explanation

A client with a history of seizures is being admitted to the emergency room after experiencing a partial seizure. Which question would be most appropriate for the nurse to ask the client?

Correct Answer is C

Explanation

A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen?

A nurse is discussing gout with a patient who is concerned about developing the disorder. Which of the following findings should the nurse identify as risk factors for this disease? Select all that applies.

A nurse is caring for a patient who has rheumatoid arthritis. Which of the following laboratory tests are used to diagnose the disease? (Select all that apply)

A nurse is assessing a 28-year-old client with HIV who has been admitted with pneumonia. Which of the following observations should the nurse prioritize?

A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching?

A nurse is caring for a client who is taking naproxen following an exacerbation of rheumatoid arthritis. Which of the following statements by the client requires further discussion by the nurse?

A client comes to the clinic with a complaint of pain in the right great toe and is eventually diagnosed with gout. When planning teaching for this client, what management technique should the nurse emphasize?

A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE). The nurse should recognize the need for further teaching when the client identifies which of the following as a factor that can exacerbate SLE?