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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.5"]
Explanation
Volume to administer (mL) = Dose ordered (mg) / Concentration of drug (mg/mL).
For a dose of 15 mg and a concentration of 10 mg/mL, the calculation would be 15 mg / 10 mg/mL = 1.5 mL.
Therefore, the nurse should administer 1.5 mL of morphine injection.
Correct Answer is D
Explanation
D. Numbness and tingling of the hands and feet can indicate peripheral neuropathy, a known adverse effect of nitrofurantoin. It's essential for the nurse to recognize and communicate the potential seriousness of these symptoms to the client.
A. Numbness and tingling are not typically related to hydration status. While adequate hydration is important for overall health, it does not directly prevent numbness and tingling caused by medication side effects.
B. Symptoms like urinary frequency, burning, and dysuria are common symptoms of a urinary tract infection, not indicators of the medication working.
C Numbness and tingling of the hands and feet can be indicative of peripheral neuropathy, which is a potential adverse reaction to nitrofurantoin. While not all cases are severe, it's crucial to assess the severity and duration of these symptoms and notify the healthcare provider.
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