A nurse is caring for a client who had IV fluids initiated at 0330. The IV fluids are infusing at 120 mL/hr. The nurse should record how many mL of IV fluids on the intake record at 0600?

Answer and Explanation

The Correct Answer is ["300"]

To calculate the volume of IV fluids infused from 0330 to 0600, you would determine the number of hours that have passed.

From 0330 to 0600 is 2.5 hours. Since the IV is infusing at 120 mL/hr, you would multiply the infusion rate by the number of hours. So, 120 mL/hr * 2.5 hours = 300 mL.

Therefore, the nurse should record 300 mL of IV fluids on the intake record at 0600.

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Correct Answer is B

Explanation

A. Metabolic alkalosis is characterized by a high pH (>7.45) and an elevated bicarbonate (HCO3-). The ABG results show a pH of 7.32 (which is acidic), PaCO2 of 48 mm Hg (slightly elevated), and HCO3- of 23 mEq/L (within normal range). These findings do not indicate metabolic alkalosis.
B. Respiratory acidosis is characterized by a low pH (<7.35) and an elevated PaCO2 (>45 mm Hg). The ABG results show a pH of 7.32 (acidic) and a PaCO2 of 48 mm Hg (slightly elevated). These findings are consistent with respiratory acidosis, where the elevated PaCO2 indicates inadequate ventilation leading to retention of carbon dioxide and subsequent acidosis.

C. Metabolic acidosis is characterized by a low pH (<7.35) and a decreased bicarbonate (HCO3-). The ABG results show a pH of 7.32 (acidic) and HCO3- of 23 mEq/L (normal). These findings are not indicative of metabolic acidosis.
D. Respiratory alkalosis is characterized by a high pH (>7.45) and a decreased PaCO2 (<35 mm Hg). The ABG results show a pH of 7.32 (acidic) and a PaCO2 of 48 mm Hg (elevated). These findings do not indicate respiratory alkalosis.

A. Spontaneous bleeding B. Infection C. Oliguria D. Hyperactive deep tendon reflexes

Correct Answer is A

Explanation

A. Thrombocytopenia (low platelet count) predisposes the client to spontaneous bleeding. This can manifest as petechiae (small red or purple spots on the skin), purpura (larger areas of purple discoloration), mucosal bleeding (such as nosebleeds or bleeding gums), or internal bleeding (such as gastrointestinal or intracranial bleeding). Monitoring for signs of bleeding is essential to promptly intervene and prevent complications.
B. While infections can occur in any client, a low platelet count does not directly predispose the client to infection. Thrombocytopenia primarily affects hemostasis rather than immune function.
C. Oliguria refers to decreased urine output, typically less than 400 mL/day in adults. It is not directly related to thrombocytopenia but may occur in conditions affecting kidney function or fluid balance.
D. Hyperactive deep tendon reflexes can indicate neurological conditions or electrolyte imbalances but are not associated with thrombocytopenia.

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A nurse is caring for a client who had IV fluids initiated at 0330. The IV fluids are infusing at 120 mL/hr. The nurse should record how many mL of IV fluids on the intake record at 0600?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

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