A client has an order for continuous bladder irrigation. What should the nurse do with the irrigation solution on the intake and output (I&O) sheet when calculating the fluid balance for this client?
Deduct it from the total urine output.
Subtract it from the intravenous flow sheet as output.
Document the intake hourly in the urine output column.
Add it to the oral intake column.
The Correct Answer is A
Choice A Reason:
When calculating the fluid balance for a client undergoing continuous bladder irrigation (CBI), the irrigation solution must be deducted from the total urine output. This is because the irrigation fluid is not part of the client’s actual urine production but is an additional fluid introduced into the bladder to prevent or remove blood clots and ensure catheter patency. By deducting the irrigation solution from the total urine output, the nurse can accurately determine the client’s true urine output and fluid balance.
Choice B Reason:
Subtracting the irrigation solution from the intravenous flow sheet as output is incorrect. The intravenous flow sheet is used to document fluids administered intravenously, not those introduced into the bladder. Therefore, this choice does not apply to the management of continuous bladder irrigation.
Choice C Reason:
Documenting the intake hourly in the urine output column is also incorrect. The urine output column should reflect the actual urine produced by the client, not the irrigation solution. Including the irrigation solution in this column would lead to an inaccurate representation of the client’s urine output and fluid balance.
Choice D Reason:
Adding the irrigation solution to the oral intake column is incorrect as well. The oral intake column is designated for fluids consumed orally by the client. The irrigation solution is introduced directly into the bladder and should not be recorded as oral intake.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Age dose of pain medication refers to adjusting the dosage of pain medication based on the client’s age. Elderly clients often have different pharmacokinetics and pharmacodynamics compared to younger individuals, which means they may require lower doses of medication to achieve the same effect. This adjustment helps to prevent overmedication and potential side effects, ensuring safe and effective pain management for elderly clients.
Choice B Reason:
Correct method of administering your own pain medication is important for clients who are capable of self-administering their medication. However, this choice does not directly address the issue of balance deficit and the need for an assistive device. While proper medication administration is crucial, it is not the primary concern in this scenario.
Choice C Reason:
Operator can push the PCA button for you if you are asleep is not an appropriate practice. Patient-controlled analgesia (PCA) is designed to allow clients to self-administer pain medication as needed. Allowing someone else to push the button can lead to overmedication and potential complications. This choice does not address the need for an assistive device for balance deficit.
Choice D Reason:
The pain medication is delivered at your nose is not a standard method of pain medication administration. This choice is incorrect and does not relate to the client’s need for an assistive device for balance deficit. Pain medication is typically administered orally, intravenously, or through other appropriate routes, but not through the nose.
Correct Answer is ["2"]
Explanation
To determine the number of tablets per dose, follow these steps:
- Calculate the total daily dose in milligrams (mg):
- 2 grams (g) = 2000 milligrams (mg)
- Divide the total daily dose by the number of doses per day:
- 2000 mg/day ÷ 2 doses/day = 1000 mg/dose
- Determine the number of tablets per dose:
- Each tablet is 500 mg.
- 1000 mg/dose ÷ 500 mg/tablet = 2 tablets/dose
Therefore, the nurse should administer 2 tablets of 500 mg amoxicillin with each dose.
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