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.

Nursing Test Bank

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Correct Answer is C

Explanation

: Chest tube placement is done to remove air or ﬂuid from the pleural space, which is the area between the lungs and the chest wall. The chest tube drainage system is an important tool to monitor and manage the drainage from the chest tube.

It is essential that the chest tube drainage system is placed below the level of the patient's chest and the site of insertion. This is necessary to create a continuous drainage system by allowing gravity to assist in the ﬂow of air or ﬂuid out of the pleural space. If the chest tube drainage system is placed above the insertion site, the ﬂuid will not drain properly, which can cause the ﬂuid to back up into the patient's chest cavity, leading to complications such as pneumothorax or hemothorax.

Therefore, the appropriate statement regarding a chest tube is that the chest tube drainage system must be placed below the site of insertion.

A. An E KG is a painless diagnostic study. We will put stickers on your body and atach wires to assess your heart rhythm. B. This will only take a minute there is nothing to fear, we do them all the time. C. I've performed many ECGs over the years and have become an expert in doing them. D. We have many children that come to the ER and receive an ECG. they say they are painless.

Correct Answer is A

Explanation

This response provides the patient with accurate and reassuring information about the EKG procedure. It explains that the test is painless and describes what will happen during the test. The other responses do not provide as much information or reassurance to the patient.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a chest tube. Which is the following statements is appropriate regarding a chest tube?

Correct Answer is C

Explanation

Your patient is ordered an EKG upon admission to the hospital. She is very scared and states she has never had one of these diagnostic tests before. Which answer is most appropriate by the nurse regarding EKG.

Correct Answer is A

Explanation

A nurse on a cardiac care unit oversees the care of diﬀerent client’s cardiac health problems. Which action can be most appropriately delegated to personnel (UAP/CNA) when a patrent is found unresponsive?

Coughing and Deep breathing is taught to a patient to prevent recurrent pneumonia. She is educated to breathe in deeply first to over expand lung volume: this is called what?

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?

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

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?

The nurse is caring for a client with respiratory alkalosis. Which arterial blood gas data does the nurse anticipate finding?

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