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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 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.

A. Palpation of the patient's lymph nodes B. Auscultation of the patient's apical heart rate C. Palpation of the patient's liver D. Percussion of the patient's abdomen

Correct Answer is A

Explanation

Choice A rationale:
Lymph nodes are small, bean-shaped structures that play a crucial role in the immune system. They filter lymph fluid, which carries white blood cells and other immune cells throughout the body.
When the body is fighting an infection or other immune challenge, lymph nodes often swell and become tender. This is because they are actively working to filter out pathogens and activate immune cells.
Palpation of the lymph nodes can provide valuable information about the patient's immune function. The nurse can assess for enlargement, tenderness, and mobility of the lymph nodes.
Lymph node assessment is a non-invasive, painless procedure that can be performed quickly and easily.
Choice B rationale:
Auscultation of the apical heart rate is important for assessing cardiovascular function, but it does not directly assess immune function.
While heart rate can be indirectly affected by certain immune conditions (e.g., fever), it is not a primary indicator of immune system activity.
Choice C rationale:
Palpation of the liver can provide information about liver size and consistency, but it does not directly assess immune function.
The liver plays a role in immune function by producing proteins that help fight infection, but its size and consistency do not necessarily reflect its immune activity.
Choice D rationale:
Percussion of the abdomen can be used to assess the size and location of abdominal organs, but it does not directly assess immune function.
While certain immune conditions may involve abdominal organs (e.g., splenomegaly), percussion is not a primary method for assessing immune function.

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Naxlex Comprehensive Predictor Exams

A client has a prescription for seizure precaution. Which intervention should the nurse include in the plan of care?

Correct Answer is B

Explanation

A nurse is completing a focused assessment addressing a client's immune function. What should the nurse prioritize in the physical assessment?

Correct Answer is A

Explanation

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