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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A
Describing the value of eating smaller portion sizes is not appropriate. While portion control is important, this advice alone might not address the overall dietary quality and exercise component necessary for effective weight loss.
Choice B
Encouraging a well-balanced diet and moderate exercise is appropriate. This intervention focuses on promoting healthy and sustainable weight loss. A well-balanced diet helps ensure that the client is getting all the necessary nutrients while aiming for a calorie deficit for weight loss. Moderate exercise complements dietary changes and contributes to overall health and weight management.
Choice C
Exploring the reasons, the client wants to lose weight is inappropriate. While understanding the client's motivations is valuable, this doesn't directly provide guidance on how to achieve the goal of losing 10 pounds.
Choice D
Determining if the client has a history of anorexia is inappropriate. While assessing for eating disorders is important in general, assuming there's no indication of anorexia, the focus should be on providing guidance for safe and effective weight loss.
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.
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