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 A
Explanation
Choice A
Counting carbohydrates will ensure glucose levels stay within a normal range is accurate. When providing dietary education to a client with Type 2 diabetes mellitus, it's important to emphasize the role of carbohydrate counting in managing blood glucose levels. Carbohydrate intake significantly impacts blood sugar levels, and counting carbohydrates can help the client make informed decisions about their meals and medications to maintain glucose levels within a normal range.
Choice B
Many carbohydrates are found in starches and fruits is not accurate. Carbohydrates are present in a variety of foods, including starches (such as bread, rice, and pasta) but not fruits. Educating the client about sources of carbohydrates can help them make choices that support blood sugar management.
Choice C
It is best to count carbohydrates when it feels like blood glucose is low is not accurate. Counting carbohydrates is an ongoing practice that helps individuals with diabetes maintain consistent blood sugar levels throughout the day, not just when blood glucose feels low.
Choice D
Examples of complex carbohydrates are white rice and cereals is inaccurate. White rice and many cereals are actually exampling of simple carbohydrates. Complex carbohydrates include foods like whole grains, legumes, and vegetables. It's important to provide accurate information about carbohydrate types.
Correct Answer is A
Explanation
Choice A
Sending fluid specimen to the lab should be implemented. Cloudy green fluid aspirated from a nasogastric tube (NGT) can indicate that the tube is in the wrong place, likely in the respiratory tract (trachea) instead of the gastrointestinal tract (stomach). The green colour suggests the presence of bile, which is normally found in the stomach but not in the respiratory tract. This is a serious situation that requires immediate attention.
The most appropriate intervention in this case is to send the fluid specimen to the lab for analysis. This is important for confirmation of the content and to guide further steps. The nurse should also consult the healthcare provider to determine the appropriate course of action, which might involve removing and reinserting the NGT correctly.
Choice B
Withdrawing the NGT and reinsert should not be implemented. If the NGT is in the wrong place, reinserting it without further assessment could worsen the situation. The nurse should not reinsert the NGT until the correct placement is confirmed.
Choice C
Connecting the NGT to wall suction should not be implemented. Connecting the NGT to wall suction without verifying its placement could cause harm, especially if the tube is in the respiratory tract.
Choice D
Determine pH value of specimen should not be implemented. While assessing the pH of aspirated fluid can help confirm the location of the NGT, sending the specimen to the lab for analysis is a more comprehensive action in this situation, as it allows for more detailed examination and guidance for appropriate next steps.
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