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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D,A,E,C,B
Explanation
The nurse should first stop the infusion (D) to prevent further infiltration of the vesicant solution. Next, the nurse should attach a syringe to the catheter (E) to prepare for aspiration.
Following this, the nurse should aspirate the solution from the catheter (C) to remove as much of the vesicant as possible. After aspiration, the nurse should disconnect the tubing from the catheter (A), ensuring that no additional vesicant is administered. Finally, the nurse should remove the IV catheter (B) to prevent any further exposure to the vesicant.
Correct Answer is ["A","B","D"]
Explanation
A. Streak formation along the vein is a characteristic sign of phlebitis. It indicates inflammation and possibly thrombophlebitis (inflammation with clot formation) within the vein.
B. Erythema (redness) at the insertion site is a common early sign of phlebitis. It indicates localized inflammation of the vein.
C. Blistering around the insertion site is not typically associated with phlebitis. It may suggest a severe reaction or infection, but it is not a common manifestation of phlebitis itself.
D. Warmth at the insertion site is a common sign of inflammation, including phlebitis. It indicates increased blood flow and localized inflammatory response.
E. A damp dressing over the insertion site can contribute to the risk of infection but is not a direct manifestation of phlebitis. However, it can be a contributing factor to the development of phlebitis if moisture leads to skin breakdown or infection.
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