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
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.
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.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.