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NurseDive Free Nursing Practice Question
How should the nurse record the net fluid intake for a client who received 0.9% sodium chloride 600 mL IV infusion, cefazolin 250 mg in dextrose 5% in water 100 mL intermittent IV bolus, 200 mL emesis, 40 mL voided urine, and 20 mL urine from straight catheterization?
A. 620 mL.
Step 1: Calculate the total fluid intake. The client received 0.9% sodium chloride 600 mL IV infusion and cefazolin 250 mg in dextrose 5% in water 100 mL intermittent IV bolus. So, the total fluid intake is 600 mL + 100 mL = 700 mL. Step 2: Calculate the total fluid output. The client had 200 mL emesis, 40 mL voided urine, and 20 mL urine from straight catheterization. So, the total fluid output is 200 mL + 40 mL + 20 mL = 260 mL. Step 3: Calculate the net fluid intake. The net fluid intake is the total fluid intake minus the total fluid output. So, the net fluid intake is 700 mL - 260 mL = 440 mL. Therefore, the nurse should record the net fluid intake as 440 mL.
B. 460 mL.
Step 1: Calculate the total fluid intake. The client received 0.9% sodium chloride 600 mL IV infusion and cefazolin 250 mg in dextrose 5% in water 100 mL intermittent IV bolus. So, the total fluid intake is 600 mL + 100 mL = 700 mL. Step 2: Calculate the total fluid output. The client had 200 mL emesis, 40 mL voided urine, and 20 mL urine from straight catheterization. So, the total fluid output is 200 mL + 40 mL + 20 mL = 260 mL. Step 3: Calculate the net fluid intake. The net fluid intake is the total fluid intake minus the total fluid output. So, the net fluid intake is 700 mL - 260 mL = 440 mL. Therefore, the nurse should record the net fluid intake as 440 mL.
C. 520 mL.
Step 1: Calculate the total fluid intake. The client received 0.9% sodium chloride 600 mL IV infusion and cefazolin 250 mg in dextrose 5% in water 100 mL intermittent IV bolus. So, the total fluid intake is 600 mL + 100 mL = 700 mL. Step 2: Calculate the total fluid output. The client had 200 mL emesis, 40 mL voided urine, and 20 mL urine from straight catheterization. So, the total fluid output is 200 mL + 40 mL + 20 mL = 260 mL. Step 3: Calculate the net fluid intake. The net fluid intake is the total fluid intake minus the total fluid output. So, the net fluid intake is 700 mL - 260 mL = 440 mL. Therefore, the nurse should record the net fluid intake as 440 mL.
D. 440 mL.
Step 1: Calculate the total fluid intake. The client received 0.9% sodium chloride 600 mL IV infusion and cefazolin 250 mg in dextrose 5% in water 100 mL intermittent IV bolus. So, the total fluid intake is 600 mL + 100 mL = 700 mL. Step 2: Calculate the total fluid output. The client had 200 mL emesis, 40 mL voided urine, and 20 mL urine from straight catheterization. So, the total fluid output is 200 mL + 40 mL + 20 mL = 260 mL. Step 3: Calculate the net fluid intake. The net fluid intake is the total fluid intake minus the total fluid output. So, the net fluid intake is 700 mL - 260 mL = 440 mL. Therefore, the nurse should record the net fluid intake as 440 mL.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Fundamentals 2019 with NGN Proctored Exam. Take the full exam now
Full Explanation
Step 1: Calculate the total fluid intake. The client received 0.9% sodium chloride 600 mL IV infusion and cefazolin 250 mg in dextrose 5% in water 100 mL intermittent IV bolus. So, the total fluid intake is 600 mL + 100 mL = 700 mL.
Step 2: Calculate the total fluid output. The client had 200 mL emesis, 40 mL voided urine, and 20 mL urine from straight catheterization. So, the total fluid output is 200 mL + 40 mL + 20 mL = 260 mL.
Step 3: Calculate the net fluid intake. The net fluid intake is the total fluid intake minus the total fluid output. So, the net fluid intake is 700 mL - 260 mL = 440 mL.
Therefore, the nurse should record the net fluid intake as 440 mL.
Similar Questions
What findings should the nurse expect when assessing an older adult client?
A. Heightened sense of pain.
Choice A is wrong because older adults may actually have a decreased sense of pain.
B. Increased nighttime sleeping.
Choice B is wrong because older adults may experience changes in their sleep patterns, including difficulty falling asleep or staying asleep.
C. Decreased sense of balance.
As people age, they may experience a decrease in their sense of balance. This can increase the risk of falls and injuries.
D. Nighttime urinary incontinence.
Choice D is wrong because while urinary incontinence can be a common issue among older adults, it is not limited to nighttime.
Full Explanation
As people age, they may experience a decrease in their sense of balance. This can increase the risk of falls and injuries.
Choice A is wrong because older adults may actually have a decreased sense of pain.
Choice B is wrong because older adults may experience changes in their sleep patterns, including difficulty falling asleep or staying asleep.
Choice D is wrong because while urinary incontinence can be a common issue among older adults, it is not limited to nighttime.
A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr.
Which of the following actions should the nurse take first?
A. Offer pain medication.
Choice A is wrong because while offering pain medication may provide temporary relief, it does not address the underlying cause of the client’s symptoms.
B. Auscultate bowel sounds.
The nurse should first auscultate the client’s bowel sounds. This will provide important information about the client’s gastrointestinal function and can help determine the cause of the client’s symptoms.
C. Palpate the abdomen.
Choice C is wrong because palpating the abdomen before auscultating bowel sounds can alter the bowel sounds and make it more difficult to accurately assess the client’s condition.
D. Administer an antiemetic.
Choice D is wrong because administering an antiemetic may provide temporary relief from nausea and vomiting, but it does not address the underlying cause of the client’s symptoms.
Full Explanation
The nurse should first auscultate the client’s bowel sounds.
This will provide important information about the client’s gastrointestinal function and can help determine the cause of the client’s symptoms.
Choice A is wrong because while offering pain medication may provide temporary relief, it does not address the underlying cause of the client’s symptoms.
Choice C is wrong because palpating the abdomen before auscultating bowel sounds can alter the bowel sounds and make it more difficult to accurately assess the client’s condition.
Choice D is wrong because administering an antiemetic may provide temporary relief from nausea and vomiting, but it does not address the underlying cause of the client’s symptoms.
A nurse is caring for a client who has a new diagnosis of terminal cancer.
Which of the following interventions is the priority?
A. Discuss the client's prior coping mechanisms.
The priority intervention for a client with a new diagnosis of terminal cancer is to discuss the client’s prior coping mechanisms. This can help the nurse understand how the client has dealt with difficult situations in the past and can provide insight into how the client may cope with their current diagnosis.
B. Teach the client to use progressive relaxation techniques.
Choice B is wrong because while teaching the client to use progressive relaxation techniques may be helpful in managing stress and anxiety, it is not the priority intervention.
C. Help the client to find a local support group.
Choice C is wrong because while helping the client find a local support group may provide emotional support, it is not the priority intervention.
D. Develop a list of goals with the client.
Choice D is wrong because while developing a list of goals with the client may provide direction and focus, it is not the priority intervention.
Full Explanation
The priority intervention for a client with a new diagnosis of terminal cancer is to discuss the client’s prior coping mechanisms.
This can help the nurse understand how the client has dealt with difficult situations in the past and can provide insight into how the client may cope with their current diagnosis.
Choice B is wrong because while teaching the client to use progressive relaxation techniques may be helpful in managing stress and anxiety, it is not the priority intervention.
Choice C is wrong because while helping the client find a local support group may provide emotional support, it is not the priority intervention.
Choice D is wrong because while developing a list of goals with the client may provide direction and focus, it is not the priority intervention.