A nurse is caring for a client who has diabetic ketoacidosis. During the shift, the client received 0.45% sodium chloride IV at 500 mL/hr for 3 hr, then at 200 mL/hr for 3 hr, and then dextrose 5% in water at 75 mL/hr for 2 hr. What is the total volume the nurse should document for the client's IV fluid intake? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
The Correct Answer is ["2250"]
To calculate the total volume of IV fluid intake, we need to calculate the volume administered during each time period and then sum them up.
First 3 hours: 500 mL/hr * 3 hr = 1500 mL
Next 3 hours: 200 mL/hr * 3 hr = 600 mL
Last 2 hours: 75 mL/hr * 2 hr = 150 mL
Now, we add these volumes together:
1500 mL + 600 mL + 150 mL = 2250 mL
Therefore, the total volume the nurse should document for the client's IV fluid intake is 2250 mL.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Weigh the client every 48 hr. – Clients with anorexia nervosa should be weighed daily at the same time to monitor for fluctuations in weight and refeeding complications.
B. Allow the client to eat meals in his room. – Clients should eat meals in a monitored dining area to prevent food hoarding, purging, or avoidance of meals.
C. Observe the client for 1 hr after meals. – This is the correct answer because clients with anorexia nervosa are at risk of purging or excessive exercise after meals. Close observation helps prevent these behaviors.
D. Obtain the client’s vital signs every other day. – Vital signs should be monitored daily or more frequently if the client is medically unstable.
Correct Answer is B
Explanation
Rationale:
A. Call the nurse who made the error to discuss the medication error – This is not the appropriate action. The focus should be on client safety and proper reporting, not on discussing the error with the previous nurse.
B. File an incident report within 24 hr – This is the correct action. Incident reports should be completed promptly to document the error and ensure proper follow-up.
C. Notify the facility's pharmacist within 1 hr of the incident – While the pharmacist may be informed if a medication reversal or adjustment is needed, this is not the primary action to take.
D. Place an incident report in the client’s medical record – Incident reports are internal documents and should not be placed in the medical record to avoid legal concerns.
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