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:
Flu-like symptoms: These are common during the early stages of HIV infection, often within 2-4 weeks after exposure to the virus. They are a result of the body's immune system responding to the virus. Symptoms can include:
Fever Fatigue
Muscle aches
Headache Sore throat
Rash
Swollen lymph nodes
Night sweats: These are also common in early HIV infection and can be caused by the body's attempts to fight off the virus or by inflammation. They can also be a side effect of some HIV medications.
Choice B rationale:
Kaposi's sarcoma (KS): This is a type of cancer that is associated with HIV infection. It is caused by a virus called Kaposi's sarcoma-associated herpesvirus (KSHV). KS often appears as purple or red lesions on the skin or in the mouth. It can also affect other organs, such as the lungs and lymph nodes. However, it's not a common initial symptom of HIV infection. It usually develops in later stages of HIV when the immune system is severely weakened.
Choice C rationale:
Fungal and bacterial infections: People with HIV are more susceptible to infections because the virus weakens their immune system. However, fungal and bacterial infections are not typically among the initial symptoms of HIV infection. They usually occur in later stages of the disease when the immune system is more compromised.
Choice D rationale:
Pneumocystis lung infection (PCP): This is a serious lung infection that is caused by a fungus called Pneumocystis jirovecii. It is a common opportunistic infection in people with HIV, but it is not typically an initial symptom. It usually develops in later stages of HIV when the CD4 count (a measure of immune system health) is very low.
Correct Answer is B
Explanation
Choice A is incorrect. While keeping the bed in a high position can minimize fall risk, it is not a specific precaution for preventing seizures. In fact, some types of seizures can be triggered by sudden changes in position.
Choice C is incorrect. Bright lights can worsen seizure activity and should be avoided, especially during the night when the client is more likely to be photosensitive.
Choice D is incorrect. Locking the bed in the lowest position can increase fall risk and is not a specific precaution for preventing seizures.
Rationale for Choice B:
Having seizure medication readily available at the bedside allows for immediate administration in case of a seizure, which can minimize its duration and severity. This is a crucial intervention for seizure precaution.
Keeping the medication within easy reach also ensures prompt administration by healthcare personnel or caregivers, further improving the client's safety and outcome.
Additionally, easy access to the medication empowers the client or caregiver to participate actively in their own care and respond quickly to a potential seizure.
Therefore, based on the importance of immediate access to seizure medication in managing and preventing seizures, Choice B is the most appropriate intervention to include in the client's plan of care.
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