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?
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Candidiasis, also known as thrush, is a fungal infection caused by Candida albicans. It commonly affects the mouth, causing white patches on the tongue, inner cheeks, gums, or tonsils.
Individuals with AIDS often have weakened immune systems due to a decreased CD4 T-cell count. This makes them more susceptible to opportunistic infections like candidiasis.
The fungal infection can spread to the esophagus, causing difficulty swallowing, or even to the bloodstream, leading to more serious complications.
Choice B rationale:
Xerostomia refers to dry mouth. It can be caused by various factors, including medications, salivary gland dysfunction, or radiation therapy. While it can occur in individuals with AIDS, it's not directly linked to a decreased CD4 T-cell count.
Choice C rationale:
Halitosis, or bad breath, can have multiple causes, including poor oral hygiene, gum disease, or digestive issues. It's not specifically associated with AIDS or a decreased CD4 T-cell count.
Choice D rationale:
Gingivitis is inflammation of the gums, often caused by plaque buildup. It's a common condition, but it's not directly linked to AIDS or a decreased CD4 T-cell count.
Correct Answer is A
Explanation
Choice A:
Fibromyalgia is a chronic condition characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive difficulties. Activity intolerance is a common symptom, resulting in patients experiencing increased fatigue, pain, and decreased function with exertion.
A program of regular mild to moderate exercise is considered the cornerstone of management for fibromyalgia. Exercise improves physical fitness, reduces pain intensity, and enhances sleep quality. It also decreases fatigue and depression, and improves overall well-being and quality of life. The key is to start with low-impact activities, gradually increase intensity and duration over time, and listen to the body's signals to avoid overexertion.
Here's how exercise benefits patients with fibromyalgia:
Pain reduction: Exercise releases endorphins, natural pain-relieving chemicals in the brain. It also strengthens muscles and improves joint flexibility, leading to decreased pain intensity and frequency.
Improved physical fitness: Regular exercise increases cardiovascular health, muscle strength, and endurance, allowing patients to tolerate activity better and perform daily tasks with less fatigue.
Enhanced sleep quality: Exercise can regulate sleep patterns, promoting deeper sleep and reducing nighttime pain, leading to improved energy levels and mood throughout the day.
Reduced fatigue and depression: Exercise triggers the release of mood-boosting neurotransmitters, like serotonin and dopamine, which can help alleviate symptoms of depression and fatigue commonly associated with fibromyalgia.
Improved overall well-being: Regular physical activity enhances self-efficacy, reduces stress, and promotes social interaction, contributing to a better quality of life for patients with fibromyalgia.
Therefore, a program of regular mild to moderate exercise is the most effective recommendation for patients with fibromyalgia to address activity intolerance and improve their overall well-being.
Rationale for other choices:
Choice B: While daily meditation and guided imagery can be helpful for managing stress and improving sleep in fibromyalgia, they are not as effective as exercise in directly addressing activity intolerance and improving physical fitness and function.
Choice C: Referral to physical therapy for an assistive device may be necessary in some cases with severe limitations, but it is not the first-line intervention for addressing activity intolerance in most patients with fibromyalgia. Exercise should be the initial focus, with assistive devices considered later if needed.
Choice D: NSAID medications can offer temporary pain relief, but they do not address the underlying cause of activity intolerance in fibromyalgia and can have side effects like gastritis and kidney problems. NSAIDs should be used cautiously and only as a complementary therapy alongside exercise in managing fibromyalgia symptoms.
Remember, a tailored exercise program, starting with low-impact activities and gradually increasing intensity, is the key to managing activity intolerance and improving function in patients with fibromyalgia.
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