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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A

Apples and blueberries are incorrect. While apples and blueberries are sources of nutrients, they are not as high in potassium as avocados and bananas.

Choice B

Avocados and bananas are correct. Chronic kidney disease (CKD) often requires dietary modifications to manage electrolyte and mineral imbalances. In CKD stage 4, the kidney's ability to filter waste and excess substances from the blood is significantly impaired. Therefore, certain foods that are high in potassium should be limited to prevent hyperkalaemia (elevated blood potassium levels).

Choice C

Cherries and cranberries are incorrect. Cherries and cranberries are also sources of nutrients, but their potassium content is not as high as that of avocados and bananas.

Choice D

Carrots and green beans are incorrect. Carrots and green beans are vegetables that are generally lower in potassium compared to fruits like avocados and bananas.

A. Protein. B. Carbohydrates. C. Dairy. D. Fats

Correct Answer is B

Explanation

Choice A

Protein is not essential. While protein can influence blood sugar levels to some extent, its effect is much smaller compared to carbohydrates. Protein is not typically counted as a primary factor in insulin dosing.

Choice B

Carbohydrates are essential. For a client with type 1 diabetes mellitus who uses both short-acting (mealtime) and long-acting (basal) insulin, counting carbohydrates is essential for meal planning and insulin dosing. Carbohydrates have the most direct and significant impact on blood sugar levels. When carbohydrates are consumed, they are broken down into glucose, which enters the bloodstream and can lead to increased blood sugar levels

Choice C

Dairy is not essential. Dairy products can contain carbohydrates (such as lactose), but the carbohydrate content varies and is not as significant as in foods like grains, fruits, and starchy vegetables.

Choice D

Fats are not essential. Fats have minimal direct impact on blood sugar levels. However, they can affect the overall rate of digestion and absorption of carbohydrates, potentially influencing the timing of insulin administration. But carbohydrate counting remains the primary focus for insulin adjustment.

View Question and Answer

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client admitted with chronic kidney disease advancing to stage 4. The nurse should instruct the client to limit the ingestion of which type of foods?

Correct Answer is B

Explanation

The nurse is caring for a client diagnosed with type 1 diabetes mellitus who uses both short-acting and long-acting insulin adjusted doses throughout the day. Which nutrient is essential for the client to count for each meal and snacks?

Correct Answer is B

Explanation

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?

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?

The nurse is caring for an older adult who needs to limit sodium intake. Which food should the nurse encourage the client to avoid?

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

The nurse is reviewing a nutrition plan with a client newly diagnosed with hypertension. Which statement by the client indicates an understanding of the Dietary Approaches to Stop Hypertension (DASH) diet?

While assessing placement of a nasogastric tube (NGT), the nurse aspirates cloudy green fluid into a syringe. Which intervention should the nurse implement?

The charge nurse observes a newly hired nurse who is preparing to insert a nasogastric tube. Which action by the charge nurse takes priority?