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 B

Explanation

Choice A

Client with a nasogastric tube to low, intermittent suction is not correct. While there is a risk of aspiration with a nasogastric tube in place, the tube is intended to help drain stomach contents, reducing the risk of aspiration. However, if the tube is not properly positioned or managed, there could still be some risk.

Choice B

Client who has sensory aphasia and is receiving a clear liquid diet is correct. Sensory aphasia refers to a language disorder that affects a person's ability to understand language and communication. This client may have difficulty swallowing safely and effectively, which increases the risk of aspiration. Additionally, a clear liquid diet consists of thin liquids that are more likely to be aspirated compared to thicker fluids.

Choice C

Client receiving 30% oxygen via a non-rebreather face mask is not correct. Oxygen therapy can increase the risk of drying the airways and potentially increasing the risk of aspiration, but if the oxygen mask is properly fitted and humidified, the risk may be minimized.

Choice D

Client experiencing dysphagia who is prescribed a full liquid diet is not correct. Dysphagia refers to difficulty swallowing, which can increase the risk of aspiration. However, a full liquid diet includes thicker liquids that are less likely to be aspirated compared to thin liquids. Still, the risk of aspiration exists, especially if the client has severe dysphagia.

A. Coffee. B. Hot tea. C. Orange juice. D. Apple juice

Correct Answer is C

Explanation

Choice A

Coffee is incorrect. Coffee can inhibit iron absorption and is not a good choice for increasing iron intake.

Choice B

Hot tea is incorrect. Similar to coffee, some compounds in tea can interfere with iron absorption, making it less optimal for increasing iron intake.

Choice C

Orange juice is correct. Orange juice is a great choice as it is high in vitamin C, which can enhance the absorption of iron from plant-based sources like oatmeal. The vitamin C in orange juice helps convert non-heme iron into a form that is more easily absorbed by the body.

Choice D

Apple juice is incorrect. While apple juice is a source of fluids, it doesn't provide the same level of vitamin C as orange juice, which is important for enhancing iron absorption.

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Naxlex Comprehensive Predictor Exams

Which client is at greatest risk for aspiration?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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

A client with celiac disease selects a bowl of oatmeal with fresh fruit and skim milk, grapefruit juice, and coffee from the breakfast menu. Which action is most important for the nurse to implement?

A client expresses an interest in reducing intake of saturated fats and plans to stop eating hamburgers at lunch. Which menu item should the nurse suggest as an alternative source of protein?

The nurse is providing care for a client with an absolute neutrophil count (ANC) of 400. Which action should the nurse perform prior to delivering the meal tray to the client's room? Reference Range Neutrophils (ANC) [Reference Range: 2500 to 8000 mm3 or 2500 to 8000 cells/uL]

The nurse is conducting diet teaching for the family of an older client who has a small reddened area on the coccyx. Based on this finding, which diet should the nurse encourage for this client?

An adult woman with a body mass index (BMI) of 21 tells the nurse that she wants to lose 10 pounds (4.5 kg). Which intervention is most important for the nurse to implement?

A young adult client with a history of iron deficiency anaemia has a haemoglobin of 10.5 g/dL (6.52 mmol/L). Which food choice should the nurse recommend to this client? Reference Range Haemoglobin (Hgb) [Reference Range: Male: 14 to 18 g/dL or 8.7 to 11.2 mmol/L]