At the end of shift, you are calculating intake and output on your pat lent who was admited for a non- emergent gall bladder removal. She is alert and oriented and able to recall the amount of ﬂuid she has drank all day. You can calculate the amount of IV ﬂuids administered. Her intake is 2500ml and her output is 1200ml from a catheter bag. You realize she is not excreting enough urine me for water she is taking in. What is the most appropriate next step to determine if she is retaining water?

Put a hat in the toilet to collect proper output.

Assess your patient’s lower extremities and lungs for ﬂuid retention.

Educate her on the importance of writing down all ﬂuids she is drinking.

Document the numbers anyway, there is a probable error with the intake number.

Answer and Explanation

The Correct Answer is B

. Assess your patient’s lower extremities and lungs for ﬂuid retention.

If a patient’s intake is 2500ml and her output is 1200ml from a catheter bag, and you are concerned that she may not be excreting enough urine for the amount of water she is taking in, the most appropriate next step would be to assess her lower extremities and lungs for ﬂuid retention. This can help determine if the patient is retaining water and if further intervention is necessary.

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Correct Answer is B

Explanation

When someone has asthma, their lungs may produce a wheezing sound when they breathe in and out. Narrowed airways and restricted air movement through the lungs may be responsible for the wheezing sound.

A. Rales B. Crackles C. Rhonchi D. Stridor

Correct Answer is B

Explanation

Crackles, also known as rales, are discontinuous sounds that are typically heard during inspiration in patients with heart failure. These sounds are produced by the sudden opening of small airways and alveoli that are filled with ﬂuid or collapsed due to pulmonary congestion. The sound can be described as similar to the sound of rubbing hair between fingers or the sound of Velcro being pulled apart.

Rhonchi are continuous, low-pitched sounds that are typically heard during expiration and are caused by the movement of air through narrowed airways, such as in patients with chronic obstructive pulmonary disease (COPD). Stridor is a high-pitched, continuous sound that is typically heard during inspiration and indicates upper airway obstruction, which can be life-threatening. Neither rhonchi nor stridor are typically heard in patients with heart failure.

Therefore, based on the patient's history and symptoms, the most likely type of breathing sound to be heard on auscultation is crackles/rales.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse provides care for the client with an asthma crisis experiencing hypoxia. Which lung sound would the nurse expect to auscultate on the physical assessment?

Correct Answer is B

Explanation

A patient presents to the Emergency Room with swollen legs and shortness of breath. He tells you that he has a history of heart failure which causes the ﬂuid to build up m his legs and lungs. When you listen to his lung sounds you are most likely to hear which type of breathing sounds?

Correct Answer is B

Explanation

The nurse is preparing to discuss safety with a group of parents of infants. When planning the program, which topics would be most important to include: (Select Al That Apply)

A dialysis unit nurse caring for a client with renal failure will expect the client to exhibit which ﬂuid imbalance?

Patient MK is admited with Atrial Fibrillation an irregular heart rhythm. She is also complaining of muscle cramps to her legs and that she started a new diuretic last week. What lab value are you most likely to find on her Complete Metabolic Panel?

A client admited with heart failure requires careful monitoring of his ﬂuid status. Which method will provide the nurse with the best indication of the client’s ﬂuid status?

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which arterial blood gas data does the nurse anticipate finding in this patient?

MA is a 85 year old female who is admited to the hospital with Pneumonia. Education has begun on proper breathing techniques to expand lung volume as much as possible and allow for proper oxygen blood exchange within the alveoli. Which device will help her achieve this as educated by the nurse?

The home care nurse visits a client with compromised lung function. The client has greenish yellow sputum with a musty odor. Which assessment is the priority for the

The nurse observes that the client’s pulse oximetry is 89%. What is the priority nursing action?