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 for the client, we need to add up the volumes of each type of fluid administered.
For 0.45% sodium chloride IV at 500 mL/hr for 3 hr:
Volume = Rate × Time = 500 mL/hr × 3 hr = 1500 mL
For 0.45% sodium chloride IV at 200 mL/hr for 3 hr:
Volume = Rate × Time = 200 mL/hr × 3 hr = 600 mL
For dextrose 5% in water at 75 mL/hr for 2 hr:
Volume = Rate × Time = 75 mL/hr × 2 hr = 150 mL
Total volume = 1500 mL + 600 mL + 150 mL = 2250 mL
Therefore, the nurse should document a total volume of 2250 mL for the client's IV fluid intake.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
A. Provide the client with a low-protein diet: Clients with severe preeclampsia may require dietary modifications, but a low-protein diet is not typically indicated. Instead, they may need a balanced diet with adequate protein intake to support maternal and fetal health.
B. Ambulate the client every 4 hr: Ambulation may not be suitable for a client with severe preeclampsia due to the risk of seizures and other complications associated with the condition. Bed rest or limited activity is often recommended to reduce the risk of adverse outcomes.
C. Ensure that the side rails are up on the client's bed: This action is crucial for the safety of the client with severe preeclampsia, as they are at risk of seizures, which can lead to injury from falls. Keeping the side rails up helps prevent falls and ensures the client's safety during periods of altered consciousness.
D. Check the fetal heart rate twice daily: Monitoring the fetal heart rate is essential in managing severe preeclampsia to assess fetal well-being and detect signs of fetal distress. However, the frequency of monitoring may vary depending on the severity of the condition and the healthcare provider's orders. More frequent monitoring may be necessary in some cases.
Correct Answer is C
Explanation
A. "Place the patch on your upper arm": Transdermal scopolamine patches are typically applied behind the ear, not on the upper arm. Placing the patch behind the ear allows for optimal absorption of the medication through the skin.
B. "Replace a dislodged patch onto the same location": If the patch becomes dislodged, it should not be reattached. Instead, a new patch should be applied to a different area behind the ear to prevent skin irritation and ensure continuous drug delivery.
C. "Apply the patch prior to traveling": This is the correct instruction. Transdermal scopolamine patches are applied to the skin at least 4 hours before travel to prevent motion sickness during the journey. Applying the patch in advance allows time for the medication to be absorbed into the bloodstream and provide effective symptom relief.
D. "Store unused patches in the refrigerator": Transdermal scopolamine patches do not typically require refrigeration. They should be stored at room temperature in a cool, dry place. Refrigeration may alter the integrity of the patch and affect its effectiveness.
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