A nurse is evaluating the 24-hr 1&O records of several clients. Which of the following client findings indicates an acceptable fluid balance?

Intake 2,400 mL, output 2.500 mL

Intake 1,200 mL, output 700 mL

Intake 800 mL output 2,100 mL

Intake 2.500 mL output 500 mL

Answer and Explanation

The Correct Answer is A

A. This indicates a slight positive fluid balance (+100 mL), meaning the client has taken in slightly more fluids than they have excreted. This could be acceptable depending on the client's clinical condition and fluid status.

B. This indicates a negative fluid balance (-500 mL), suggesting the client has excreted more fluids than they have taken in. In some situations, such as in patients with certain conditions like edema, a negative balance might be intended.

C. This indicates a significant negative fluid balance (-1,300 mL), where the client has excreted much more fluid than they have taken in. This could indicate dehydration or fluid loss that needs to be addressed promptly.

D. This indicates a significant positive fluid balance (+2,000 mL), where the client has taken in much more fluid than they have excreted. This could indicate fluid retention, which might be acceptable in certain clinical conditions but could be problematic in others, such as in patients with congestive heart failure.

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Correct Answer is C

Explanation

C. The conversion of milliliters to teaspoons is a common calculation in medication administration. Since 5 mL is equivalent to 1.01442068 teaspoons, the closest standard measurement used in medication dosing is 1 teaspoon.

A. every 5 hours B. once per shift C. hourly D. once a day

Correct Answer is C

Explanation

C. Hourly monitoring of the IV site may be necessary in situations where the patient's clinical condition requires close observation, such as when administering certain medications that can cause irritation or when rapid changes in fluid status are expected.

A. Checking the IV site every 5 hours may not be frequent enough, especially for patients who require close monitoring due to potential complications such as infiltration, phlebitis, or dislodgement of the IV catheter.

B. Correct, but it depends on the shift length. In many clinical settings, nurses typically assess the IV site once per shift to ensure proper functioning and assess for any signs of complications. However, the length of the shift can vary, and in some cases, more frequent monitoring may be necessary, especially if the patient's condition requires it.

D. Checking the IV site only once a day is generally insufficient, as it does not provide timely assessment and intervention for potential IV complications that can occur more frequently.

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A nurse is evaluating the 24-hr 1&O records of several clients. Which of the following client findings indicates an acceptable fluid balance?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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