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 C
Explanation
Choice A Reason:
Open the client’s visual acuity using a Snellen chart is incorrect. This action assesses cranial nerve II (optic nerve), which is responsible for vision. The Snellen chart is used to measure visual acuity, not the function of cranial nerve VI
Choice B Reason:
Whisper none of the client’s ears while blocking the other is incorrect. This action assesses cranial nerve VIII (vestibulocochlear nerve), which is responsible for hearing and balance. Whispering tests the auditory function of this nerve.
Choice C Reason:
Ask the client to inspect up is correct. Cranial nerve VI (abducens nerve) controls the lateral rectus muscle, which is responsible for moving the eye outward. Asking the client to look up and outward helps assess the function of this nerve.
Choice D Reason:
Ask the client to smile is incorrect. This action assesses cranial nerve VII (facial nerve), which controls the muscles of facial expression. Smiling tests the motor function of this nerve.
Correct Answer is C
Explanation
Advance directives are legal documents that allow individuals to outline their preferences for medical treatment in case they become unable to communicate their decisions. These documents typically include a living will and a durable power of attorney for healthcare. The living will specifies the types of medical treatment a person wishes to receive or avoid, while the durable power of attorney for healthcare designates a trusted individual to make healthcare decisions on their behalf.
Choice A Reason:
“I will get my regular doctor to approve my plan before I hand it in to the hospital.”
This statement indicates a misunderstanding of the purpose of advance directives. While it is important to discuss your advance directives with your healthcare provider, the primary purpose of these documents is to communicate your wishes regarding medical treatment, not to seek approval from your doctor. The advance directive is a personal document that reflects your values and preferences for medical care.
Choice B Reason:
“I know they won’t go ahead with the surgery unless I prepare these forms.”
This statement also reflects a misunderstanding. While having advance directives in place is highly recommended, it is not typically a prerequisite for undergoing surgery. Advance directives are important for ensuring that your medical wishes are respected, but they are not mandatory for surgical procedures. The focus should be on making sure your wishes are known and documented, rather than on the necessity of the forms for surgery.
Choice C Reason:
“I plan to write that I do not want them to keep me on a breathing machine.”
This statement correctly reflects the purpose of an advance directive. It shows that the patient understands that they can specify their preferences for medical treatment, such as whether or not they want to be kept on a breathing machine. This type of instruction is a common component of a living will, which is part of an advance directive. It ensures that healthcare providers are aware of the patient’s wishes regarding life-sustaining treatments.
Choice D Reason:
“I would rather have my brother make decisions for me, but I know he has to be my wife.”
This statement is incorrect and confusing. It seems to mix up the roles of different individuals. In an advance directive, you can designate a healthcare proxy or durable power of attorney for healthcare, who can be any trusted person, not necessarily a spouse. The statement also contains a factual error, as it implies that the brother must be the patient’s wife, which is not possible. The correct understanding is that you can choose any trusted individual to make healthcare decisions on your behalf.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today