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
Related Questions
Correct Answer is A
Explanation
A. Placental abruption: Placental abruption is characterized by the premature separation of the placenta from the uterine wall before delivery of the fetus. Sudden, severe abdominal pain, moderate to severe vaginal bleeding, persistent uterine contractions, and uterine rigidity are classic signs and symptoms of placental abruption. Hypotension may occur due to hemorrhage, leading to decreased perfusion to vital organs.
B. Uterine rupture: Uterine rupture involves a tear in the uterine wall, which can lead to severe abdominal pain, vaginal bleeding, and signs of shock. However, uterine rupture typically occurs during labor or delivery, particularly in women with a history of uterine surgery or trauma.
C. Placenta previa: Placenta previa is characterized by the implantation of the placenta over or near the internal cervical os. It can cause painless vaginal bleeding in the third trimester, particularly after 20 weeks of gestation. However, it is not typically associated with severe abdominal pain or uterine rigidity.
D. Amniotic fluid embolus: An amniotic fluid embolus occurs when amniotic fluid, fetal cells, hair, or other debris enter the maternal circulation, leading to a potentially life-threatening reaction. Symptoms may include sudden dyspnea, hypotension, cardiovascular collapse, and disseminated intravascular coagulation (DIC). While it can cause severe complications, the symptoms described in the scenario are more consistent with placental abruption.
Correct Answer is B
Explanation
A. Provide the client with a list of eligible individuals who can serve as a health care proxy. - While it is important for clients to have information about selecting a healthcare proxy, the Patient Self-Determination Act does not specifically require nurses to provide a list of eligible individuals. However, nurses should educate clients about their rights to designate a healthcare proxy if desired.
B. Document in the client's medical record if the client has advance directives. - This is the correct action required by the Patient Self-Determination Act. The act mandates that healthcare facilities receiving Medicare or Medicaid funds must inform clients about their rights to make decisions about their medical care, including the right to have advance directives. Nurses are responsible for documenting in the client's medical record whether the client has advance directives, such as a living will or durable power of attorney for healthcare.
C. Provide end-of-life education if the client has a terminal illness. - While providing end-of-life education is important for clients with terminal illnesses, it is not specifically mandated by the Patient Self-Determination Act. However, the act does require healthcare facilities to inform clients about their rights to make decisions about end-of-life care, including the right to have advance directives.
D. Ensure the client has an attorney to contact for assistance with end-of-life documents. - The Patient Self-Determination Act does not mandate that nurses ensure clients have an attorney for assistance with end-of-life documents. While legal assistance may be helpful for some clients in completing advance directives, it is not a requirement of the act.
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