2024/2025. GRADED A+
The nurse is calculating intake and output on a patient. The patient drinks
150 mL of orange juice at breakfast, voids 125 mL after breakfast, vomits 250
mL of greenish fluid, sucks on 60 mL of ice chips, and for lunch consumes 75
mL
of chicken broth. Which totals for intake and output will the nurse document
in the patient’s medical record?
a. Intake 255; output 375
b. Intake 285; output 375
c. Intake 505; output 125
d. Intake 535; output 125
ANS: A
Intake = 150 mL of orange juice, 60 mL of ice chips (but only counts as 30 since
ice chips are half of the amount), and 75 mL of chicken broth; 150 + 30 + 75 =
255. Output = 125 mL of urine (void) and 250 mL of vomitus; 125 + 250 = 375.
1. nurse is assessing a patient. Which assessment finding should
cause a nurse to further assess for extracellular fluid volume deficit?
a. Moist mucous membranes
b. Postural hypotension
c. Supple skin turgor
d. Pitting edema
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,ANS: B
Physical examination findings of deficit include postural hypotension,
tachycardia, thready pulse, dry mucous membranes, and poor skin turgor.
Pitting edema indicates that the patient may be retaining excess extracellular
fluid.
29.A patient is to receive 1000 mL of 0.9% sodium chloride intravenously at a
rate of 125 mL/hr. The nurse is using microdrip gravity drip tubing. Which
rate will the nurse calculate for the minute flow rate (drops/min)?
a. 12 drops/min
b. 24 drops/min
c. 125 drops/min
d. 150 drops/min
ANS: C
Microdrip tubing delivers 60 drops/mL. Calculation for a rate of 125 mL/hr
using microdrip tubing: (125 mL/1 hr)(60 drops/1 mL)(1 hr/60 min) = 125
drop/min.
30.A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and
programs the pump to infuse at 50 mL/hr. At what time should the infusion
be completed?
a. 2300 Monday
b. 2345 Monday
c. 0015 Tuesday
d. 0045 Tuesday
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, ANS: B
250 mL ÷ 50 mL/hr = 5 hr
1845 + 5 hr = 2345, which would be 2345 on Monday.
31.A nurse is caring for a diabetic patient with a bowel obstruction and has
orders to ensure that the volume of intake matches the output. In the past 4
hours, the patient received dextrose 5% with 0.9% sodium chloride through a
22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice chips.
The patient also has an NG suction tube set to low continuous suction that
had 300-mL output. The patient has voided 400 mL of urine. After reporting
these values to the health care provider, which order does the nurse
anticipate?
a. Add a potassium supplement to replace loss from output.
b. Decrease the rate of intravenous fluids to 100 mL/hr.
c. Administer a diuretic to prevent fluid volume excess.
d. Discontinue the nasogastric suctioning.
ANS: A
The total fluid intake and output equals 700 mL, which meets the provider
goals. Patients with nasogastric suctioning are at risk for potassium deficit, so
the nurse would anticipate a potassium supplement to correct this condition.
Remember to record half the volume of ice chips when calculating intake.
The other measures would be unnecessary because the net fluid volume is
equal.
32.A nurse is caring for a patient who is receiving peripheral intravenous (IV)
therapy. When the nurse is flushing the patient’s peripheral IV, the
patient reports pain. Upon assessment, the nurse notices a red streak that is
warm to the touch. What is the nurse’s initial action?
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