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
Advising the client that too much fruit can irritate the colon is not the right choice. While it's true that excessive consumption of certain fruits can cause gastrointestinal discomfort, this information is not directly related to celiac disease or the selected meal.
Choice B
Informing the client that oatmeal contains gluten is the right choice. Celiac disease is an autoimmune disorder in which consuming gluten, a protein found in wheat, rye, and barley, triggers an immune response that damages the small intestine. Oatmeal itself is naturally gluten-free, but it is often processed in facilities that also process gluten-containing grains, which can lead to cross-contamination. Therefore, it's important for individuals with celiac disease to choose certified gluten-free oats to avoid adverse reactions.
Choice C
Commending the client for selecting fat-free milk is not the best choice. While choosing a healthier milk option is beneficial for overall health, it is not the most important action in this situation, considering the client's celiac disease.
Choice D reason;
Encouraging the client to choose decaffeinated coffee is not the right choice. The choice of caffeinated or decaffeinated coffee is a matter of preference and is not directly related to celiac disease or the potential for gluten exposure from the oatmeal.
Correct Answer is A
Explanation
Choice A
Body mass index (BMI) of 17 is the correct finding. A low Body Mass Index (BMI) is a common indicator of malnutrition. BMI is a measurement that considers a person's weight in relation to their height. A BMI of 17 suggests that the person is underweight, which can be indicative of malnutrition. Malnutrition is characterized by inadequate intake of calories, protein, vitamins, and minerals that are essential for maintaining health and well-being.
Choice B
Decrease in appetite is not correct finding. While a decrease in appetite might contribute to malnutrition, it's a symptom rather than a definitive indicator.
Choice C
Dry mucosal membranes are not the correct finding. Dry mucosal membranes can be related to dehydration or other conditions, but they are not specific enough to confirm malnutrition on their own.
Choice D
Weight of 227 pounds (103 kg) is not the correct finding. This weight is not necessarily indicative of malnutrition on its own. It's important to consider the individual's height, BMI, and other factors when assessing malnutrition.
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.