After reviewing a client's intake and output record for the last eight hours, the nurse calculates the client's current fluid balance as how many mL? (Enter numeric value only).

0730-8 oz of orange juice, hard-boiled egg, and toast

0830-voided 200 mL

0900-a cup of water

1200-1 cup of soup, tuna sandwich, and 6 ounces of apple juice

1300 vomitus of 100 mL

1400-voided 250 ml

1430-12 ounce can have carbonated beverage.

The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which finding(s) should alert the nurse that further assessment is needed? (Select all that apply.)

Generalized nonpitting edema.

Hypoactive bowel sounds in all 4 quadrants.

Redness at intravenous site.

Urinary output greater than 30 ml per hour.

Frequent productive cough.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A

Generalized nonpitting edema is correct. Nonpitting edema could indicate fluid retention, and it's important to assess for signs of fluid overload, electrolyte imbalances, or underlying cardiac issues.

Choice B

Hypoactive bowel sounds in all 4 quadrants is correct. Hypoactive bowel sounds could suggest gastrointestinal motility issues, which could be a sign of gastrointestinal complications related to TPN.

Choice C

Redness at intravenous site is correct. Redness at the intravenous site could be indicative of infection, infiltration, or irritation. It's important to assess for signs of infection and ensure proper IV site care.

Choice D

Urinary output greater than 30 ml per hour is incorrect. While increased urinary output could indicate adequate hydration, it's not typically a concerning finding unless there are other signs of fluid imbalance. Top of Form

Choice E

Frequent productive cough is correct. A frequent productive cough could indicate respiratory issues, including aspiration pneumonia, which can be a complication of TPN.

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Correct Answer is C

Explanation

Choice A

Beef broth should not be omitted. Generally, clear broths like beef broth are lower in fat and may be a better choice for someone with cholelithiasis compared to creamy or fatty foods.

Choice B

Ketchup should not be omitted. Ketchup is not typically high in fat and may not be a significant concern for someone with cholelithiasis.

Choice C

Ice cream should be omitted. Cholelithiasis refers to the presence of gallstones in the gallbladder. Gallstones can form from substances in the bile, and certain foods can trigger symptoms in individuals with gallbladder issues. One of the common triggers is high-fat foods, which can cause the gallbladder to contract and potentially lead to pain or discomfort.

Choice D

Bread should not be omitted. While bread contains some fat, it's not as high in fat as ice cream. The focus for individuals with cholelithiasis is often on high-fat foods rather than moderate-fat foods like bread.

A. Urinary ketones. B. Serum protein. C. Serum osmolarity. D. Capillary glucose.

Correct Answer is C

Explanation

Choice A

Urinary ketones are not most important. Monitoring urinary ketones can provide information about the utilization of glucose and fat as energy sources. However, it is not the primary lab value to monitor in TPN administration.

Choice B

Serum protein is not most important. Monitoring serum protein levels is important to assess nutritional status, but it might not be as immediate a concern as serum osmolarity.

Choice C

Serum osmolarity is the most important. When caring for a client receiving total parenteral nutrition (TPN), monitoring serum osmolarity is most important. TPN is a highly concentrated solution containing various nutrients, and it is infused directly into the bloodstream. Serum osmolarity reflects the concentration of particles (such as electrolytes, glucose, and other solutes) in the blood. Monitoring serum osmolarity is crucial to prevent complications related to fluid and electrolyte imbalances that can arise from the administration of TPN.

Choice D

Capillary glucose is not the most important. Monitoring capillary glucose levels is important, especially in clients receiving TPN with added glucose. Hyperglycaemia is a potential complication of TPN. While glucose monitoring is important, it is secondary to monitoring serum osmolarity, which encompasses a broader range of solute concentrations.

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Naxlex Comprehensive Predictor Exams

A middle-aged client newly diagnosed with cholelithiasis is choosing the evening meal. What food choice should the nurse encourage the client to omit?

Correct Answer is C

Explanation

While caring for a client receiving total parenteral nutrition (TPN), it is most important for the nurse to monitor which of the client's lab values?

Correct Answer is C

Explanation

While caring for a client receiving total parenteral nutrition (TPN), it is most important for the nurse to monitor which of the client's lab values?

When conducting diet teaching for a client diagnosed with hypokalaemia, which foods should the nurse encourage the client to eat?

A client with glomerulonephritis is preparing for discharge and asks the nurse which kind of diet to follow upon returning home. Which dietary teaching should the nurse include in the discharge instructions?

In conducting community health teaching, the nurse plans to describe foods that will help prevent rickets. What food product should the nurse recommend as the best dietary source for preventing rickets?

The nurse is developing a food safety educational class for a group of parents. Which type of food is most likely to pose a threat of food poisoning after being stored in a refrigerator at 40°F (4.4°C) or below for more than two days?

When conducting diet teaching for a client diagnosed with hypokalaemia, which foods should the nurse encourage the client to eat?