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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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Correct Answer is A

Explanation

Choice A rationale:
Coughing and deep breathing: These techniques directly promote airway clearance by mobilizing and expelling secretions from the lungs. They are essential for clients with pneumonia, as the buildup of secretions can obstruct the airways and impair gas exchange.
Hydration maintenance: Adequate hydration helps to thin secretions, making them easier to cough up and clear from the lungs. It also helps to prevent dehydration, which can worsen respiratory symptoms.

Choice B rationale:
Keeping the head of the bed elevated: This can help to improve breathing by decreasing the work of breathing and promoting lung expansion. However, it is not the most effective intervention for directly clearing secretions from the lungs.

Choice C rationale:
Preparation for insertion of a tracheostomy tube: This is a more invasive intervention that may be necessary in severe cases of airway obstruction. However, it is not the priority intervention for a client with ineffective airway clearance related to pneumonia.

Choice D rationale:
Providing supplemental oxygen: This can help to improve oxygenation in clients with pneumonia. However, it does not directly address the problem of ineffective airway clearance.

A. Tachypnea and restlessness B. Weight loss of 1 pound since yesterday C. Frequent loose stools D. Oral temperature of 100°F

Correct Answer is A

Explanation

Rationale for Choice A:
Tachypnea and restlessness are common signs of respiratory distress, which is a potential complication of pneumonia. These signs indicate that the client's oxygenation may be compromised and require immediate attention.

Rationale for Choice B:
Weight loss of 1 pound since yesterday is a non-specific finding and could be due to a variety of factors, including poor appetite, dehydration, or muscle wasting. While weight loss can be a symptom of HIV infection, it is not an acute sign that requires immediate prioritization in this case.

Rationale for Choice C:
Frequent loose stools can be a symptom of HIV infection or a side effect of certain medications. However, it is not an acute sign that requires immediate prioritization in this case, especially in the context of the client's respiratory distress.

Rationale for Choice D:
An oral temperature of 100°F is a low-grade fever and is not a specific indicator of any serious condition. While fever can be a symptom of pneumonia, it is not the most concerning finding in this case.
Therefore, based on the client's presenting symptoms, tachypnea and restlessness are the most concerning findings and should be prioritized by the nurse.

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Naxlex Comprehensive Predictor Exams

What intervention should the nurse identify as a priority for a client with a nursing diagnosis of ineffective airway clearance related to HIV-related pneumonia?

Correct Answer is A

Explanation

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?

Correct Answer is A

Explanation

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