After reviewing the 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 150 ml
- 1200-1 cup of soup, tuna sandwich, and 1/2 cup of apple juice
- 1300 vomitus of 100 mL
- 1400 voided 250 mL and drank one 12 oz can of soft drink
The Correct Answer is ["455"]
-
Intake:
- 8 oz of orange juice = 240 mL
- 1 cup of soup = 240 mL
- 1/2 cup of apple juice = 120 mL
- 12 oz can of soft drink = 355 mL
- Total intake = 240 + 240 + 120 + 355 = 955 mL
-
Output:
- Voided 150 mL
- Vomitus 100 mL
- Voided 250 mL
- Total output = 150 + 100 + 250 = 500 mL
-
Fluid Balance:
- Fluid balance = Intake - Output = 955 - 500 = 455 mL
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A
Offering water to the client hourly is not appropriate. While staying hydrated is important for overall health, offering water hourly might not be necessary unless there is a specific indication of dehydration. However, monitoring the client's fluid intake and output is a good approach.
Choice B
Reducing dairy product intake is not appropriate. Dairy product intake is not typically associated with sudden onset confusion. Reducing dairy product intake would not be the primary intervention for addressing confusion.
Choice C
Increasing daily sodium intake is not appropriate. Increasing sodium intake is unlikely to be the appropriate intervention for confusion unless there is a specific medical reason for it. Moreover, excessive sodium intake can have negative health consequences.
Choice D
Reviewing the intake and output record is appropriate. Confusion in an older client can be caused by various factors, including medical conditions, medication side effects, dehydration, and electrolyte imbalances. Reviewing the intake and output record (option D) is a reasonable intervention to gather more information about the client's fluid balance and hydration status. This can help the nurse assess whether the confusion might be related to dehydration or electrolyte imbalances.
Correct Answer is D
Explanation
Correct answer: D
Choice A
Urinary ketones are not most important. Monitoring urinary ketones can provide information about the utilization of glucose and fat as energy sources. However, it is not the primary lab value to monitor in TPN administration.
Choice B
Serum protein is not most important. Monitoring serum protein levels is important to assess nutritional status, but it might not be as immediate a concern as serum osmolarity.
Choice C
Serum osmolarity reflects the concentration of particles (such as electrolytes, glucose, and other solutes) in the blood. Monitoring serum osmolarity is importantto prevent complications related to fluid and electrolyte imbalances that can arise from the administration of TPN.Blood glucose levels (option D) are more critical because TPN can significantly impact glucose metabolism
Choice D
When caring for a client receiving total parenteral nutrition (TPN), the nurse’spriorityis tomonitor blood glucose levels. TPN can affect blood glucose, and observing for signs of hyperglycemia or hypoglycemia is crucial.Additionally, administering insulin as directed based on blood glucose levels is essential.
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