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 D

Explanation

D. Holding the skin taut helps stabilize the area and ensures that the needle penetrates the skin smoothly and at the correct angle. This also helps prevent the needle from going too deep or slipping out of the site during injection.

A. The syringe should be held at a 5 to 15-degree angle to the client's skin, not 20 degrees.

B. For a tuberculin skin test (PPD test), typically 0.1 mL (one-tenth of a milliliter) of PPD is injected intradermally. This is a very small amount compared to 0.5 mL.

C. The length of the needle for an intradermal injection is typically shorter than 1 inch, usually around 3/8 to 5/8 inches (10-16 mm). Using a longer needle may increase the risk of inserting the needle too deeply, potentially leading to subcutaneous rather than intradermal injection.

A. most appropriate distal vein on the nondominant arm. B. most appropriate proximal vein available on either arm. C. antecubital vein of the patient's nondominant arm. D. antecubital vein of the patient's dominant arm.

Correct Answer is A

Explanation

A. Distal veins, such as those in the hand or forearm of the nondominant arm, are often preferred for initial IV placement. These veins are typically smaller but can be easier to access and cause less discomfort for the patient compared to more proximal veins.

B. Proximal veins, such as those in the upper arm (brachial or basilic veins), may be considered if distal veins are not accessible or suitable. However, proximal veins are larger and can be more difficult to cannulate, potentially causing more discomfort and increasing the risk of complications.

C. The antecubital veins, located in the bend of the elbow, are commonly used for venipuncture due to their accessibility and size. The antecubital vein of the nondominant arm is often preferred to minimize interference with the patient's daily activities and reduce the risk of complications associated with frequent use of the dominant arm.

D. While the antecubital vein of the dominant arm may also be accessible, it is generally recommended to preserve this area for procedures that require a higher level of dexterity and strength. Frequent venipuncture in the dominant arm can lead to discomfort and potential complications, such as phlebitis or thrombosis.

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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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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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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?