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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Stridor is a high-pitched, inspiratory sound that indicates partial obstruction of the upper airway. It is a common finding in newborns and can occur due to the presence of mucus, fluid, or a small airway that has not yet fully developed. It is important to note that while stridor is an expected finding in newborns, it should still be assessed and monitored closely by healthcare professionals.
Bruits are abnormal sounds heard over blood vessels and are not related to breath sounds. Crackles are a series of brief, discontinuous, nonmusical sounds heard during inspiration or expiration, indicating fluid in the lungs. Wheezing is a high-pitched, musical sound heard during expiration and can indicate the narrowing of the airways. These sounds are not typically expected in the breath sounds of a newborn.
Correct Answer is C
Explanation
Booster seats are recommended for children between the ages of 4 and 8, or until they are 4'9" tall. This is because seat belts are designed for adults and may not properly fit a child's smaller body. A booster seat helps to position the seat belt correctly on the child's body, improving the effectiveness of the seat belt and reducing the risk of injury in the event of a crash.
Option a is incorrect because 10 years old is too old to need a car seat. Option b is incorrect because children under the age of 8, or under 4'9" tall, should not use a seat belt alone. Option d is incorrect because car seats are recommended until children are at least 4 years old, not 3.
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