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 B
Explanation
B. Sharps containers should be replaced when they are 3/4 full to prevent overfilling, which could increase the risk of needlesticks when trying to dispose of sharps. Ensuring sharps containers are not overfilled helps maintain a safe environment by reducing the risk of accidental puncture injuries during disposal.
A. Used razors should be disposed of in puncture-resistant sharps containers, not in regular wastebaskets. Sharps containers are specifically designed to safely contain sharp objects to prevent accidental injuries.
C. Using two hands to recap a needle is unsafe and increases the risk of accidental needlestick injuries. It's important to educate healthcare workers to avoid recapping needles whenever possible.
D. Breaking needles before disposal is unsafe and increases the risk of injury. Needles should be disposed of intact in a puncture-resistant sharps container.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.