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 A
Explanation
A. IV solutions and administration sets should typically be changed every 48 to 72 hours to reduce the risk of contamination and infection. This interval helps prevent the buildup of bacteria in the solution and tubing, which could lead to bloodstream infections (BSIs).
B. Checking the client's IV site every is also important for monitoring for signs of infection, infiltration, or phlebitis. However, every 8 hours is too frequent and unnecessary
C. IV tubing should be changed every 72 hours not every 96 hours. Prolonging the use of IV tubing beyond this timeframe increases the risk of bacterial contamination and infection.
D. Transparent dressings are usually changed every 5 to 7 days, or sooner if they become soiled or compromised.
Correct Answer is B
Explanation
B. Before administering any medication, especially antibiotics like amoxicillin, the nurse must assess the patient for allergies or previous adverse reactions to amoxicillin or other beta-lactam antibiotics. Allergic reactions can range from mild rashes to severe anaphylactic reactions, so it's essential to confirm the
patient's allergy status and assess for any signs or symptoms of allergic reaction before proceeding with administration.
A. Flushing the IV site with normal saline is typically not required specifically before administering IV amoxicillin unless it is part of the institution's standard practice to flush all IV lines before and after medication administration.
C. While monitoring intake and output (I&O) is important for assessing fluid balance and kidney function, it is not directly necessary before administering IV amoxicillin unless there are specific concerns related to the patient's fluid status or renal function. However, it is good practice to have a general understanding of the patient's recent fluid intake and output patterns.
D. Creatinine clearance is a measure of kidney function. Checking the latest creatinine clearance result is important for assessing renal function, especially before administering medications excreted by the kidneys. However, amoxicillin is primarily excreted by the kidneys in its unchanged form, so knowing the patient's renal function status can help in determining the appropriate dosage or adjusting the dosing interval if necessary.
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