The nurse is caring for a client who has a continuous bladder irrigation (CBI) infusing. At the end of the shift, the nurse calculates the urine output. The client received a total of 2700 mL of the irrigation and emptied a total of 3375 ml from the urine catheter. What should the nurse record as the client's true urine output?
-625 mL
+675 mL
+375 mL
-300 mL
The Correct Answer is B
A. A negative output would imply that the client has produced less urine than the irrigation received, which is not the case here.
B. The true urine output is 675 mL, calculated by subtracting the irrigation amount from the total urine collected.
C. The calculation does not support this value, as it does not accurately reflect the total urine output after accounting for the irrigation.
D. Similar to option A, a negative value does not apply here since the urine output exceeds the irrigation amount.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Bacitracin is an antibiotic ointment typically used to prevent or treat bacterial infections in minor cuts and scrapes. It is not appropriate for treating a pruritic rash associated with GVHD. The rash may not be due to an infection but rather an immune response, so using bacitracin would not address the underlying issue.
B. Diphenhydramine (Benadryl) and hydroxyzine are antihistamines that can help alleviate itching and provide relief from pruritus. Requesting a prescription for one of these medications is an appropriate response to manage the symptoms of GVHD.
C. Showering with cool water can soothe irritated skin and reduce itching. Using mild soap helps to avoid further irritation or dryness that harsher soaps can cause. This intervention supports skin care and helps manage pruritus effectively.
D. Clipping fingernails can help prevent skin damage from scratching, which could lead to secondary infections. Encouraging the use of prescribed lotions can help keep the skin moisturized and alleviate dryness, further addressing the pruritus associated with GVHD.
Correct Answer is C
Explanation
A. An ischemic stroke occurs when a blood vessel supplying blood to the brain is obstructed. Common symptoms include sudden numbness or weakness in the face, arm, or leg, confusion, difficulty speaking, and visual disturbances. However, "thunderclap" headache and neck stiffness are not typical symptoms of an ischemic stroke.
B. A TIA, often referred to as a "mini-stroke," produces similar symptoms to a stroke but lasts for a short duration (typically less than 24 hours) and does not cause permanent damage. Symptoms can include weakness, speech difficulties, and visual changes, but again, "thunderclap" headache and neck stiffness are not characteristic of a TIA.
C. A subarachnoid hemorrhage occurs when there is bleeding into the space between the brain and the tissues covering it, often due to a ruptured aneurysm. A "thunderclap" headache, described as an extremely sudden and severe headache, is a hallmark of this condition.
D. A cardioembolic stroke is a type of ischemic stroke that occurs when a blood clot forms in the heart and travels to the brain. Symptoms are similar to those of an ischemic stroke and do not typically include a "thunderclap" headache or neck stiffness.
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