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: Thrombophlebitis is characterized by inflammation of the vein with the formation of a blood clot. The signs and symptoms include erythema, warmth, edema, and a red line traveling up the vessel, which indicates the presence of inflammation and possible clot formation. This condition requires prompt intervention to prevent further complications such as the spread of infection or the clot traveling to other parts of the body.
Choice B reason: Infiltration occurs when IV fluid or medication leaks into the surrounding tissue. Signs of infiltration include swelling, discomfort, and coolness at the IV site, but it does not typically present with erythema, warmth, or a red line traveling up the vessel. Infiltration is less likely to cause the systemic signs seen in this case.
Choice C reason: Infection at the IV site can cause erythema, warmth, and edema, but it usually does not present with a red line traveling up the vessel. The red line is more indicative of thrombophlebitis, where the inflammation follows the path of the vein. Infection would also likely present with additional systemic signs such as fever.
Choice D reason: Extravasation involves the leakage of vesicant drugs into the surrounding tissue, causing severe local tissue damage. Signs include pain, burning, and blistering at the site, but it does not typically present with a red line traveling up the vessel. Extravasation is more localized and does not follow the vein’s path like thrombophlebitis.
Correct Answer is ["A"]
Explanation
Choice A reason: Pee privacy
Ensuring privacy for a patient, especially one who is pregnant, is crucial. Privacy helps maintain the patient’s dignity and comfort during medical procedures. It also fosters a trusting relationship between the patient and the healthcare provider. In this context, “Pee privacy” likely refers to ensuring the patient has privacy when providing a urine sample, which is a common procedure during pregnancy check-ups to monitor for conditions like gestational diabetes or preeclampsia.
Choice B reason: Otoscope
An otoscope is a medical device used to look into the ears. While it is an essential tool in many medical examinations, it is not specifically related to the care of a pregnant patient unless there is a specific concern about ear health. Therefore, this choice is less relevant in the context of routine pregnancy care.
Choice C reason: Tannic acid
Tannic acid is a substance that can be used for various medical purposes, including treating burns and stopping bleeding. However, it is not typically associated with routine pregnancy care. Its inclusion in this list seems out of place unless there is a specific, unusual medical condition being addressed.
Choice D reason: Pupil dilation
Pupil dilation is a procedure often performed during eye examinations to allow a better view of the retina and other structures inside the eye. While important in ophthalmology, it is not a standard procedure in the care of a pregnant patient unless there is a specific concern about the patient’s vision or eye health.
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