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Extract:

Intake and output record

Emesis 120 mL
Wet diaper 1 50 g
Wet diaper 2 52 g
Wet diaper 3 46 g

*Weight of a dry diaper = 30 g
Intake and output record


Question 1 of 5

The nurse is calculating a client's intake and output for the shift. How many mL should the nurse record as the client's output?

Correct Answer: 208

Rationale: Emesis (120 mL) plus diaper output (50-30=20 mL, 52-30=22 mL, 46-30=16 mL) totals 120+20+22+16=208 mL.

Extract:


Question 2 of 5

The daughter of an 80-year-old client recently diagnosed with Alzheimer disease (AD) says to the nurse, 'I guess I can anticipate getting this disease myself at some point.' What is an appropriate response by the nurse?

Correct Answer: A

Rationale: Regular exercise is associated with a reduced risk of Alzheimer disease. Family history is a risk factor, and aluminum is not a proven cause.

Question 3 of 5

A client with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia has been receiving IV vancomycin for the last 3 days. Which blood test trend is most important for the nurse to review when preparing to administer this medication?

Correct Answer: B

Rationale: Vancomycin can cause nephrotoxicity, so monitoring creatinine levels is critical to assess kidney function.

Question 4 of 5

A behavior modification program is planned for an adolescent who exhibits disruptive behavior. Which action by the nurse is most consistent with a behavior modification program?

Correct Answer: B

Rationale: Positive reinforcement (extra privileges for non-disruptive behavior) aligns with behavior modification, encouraging desired actions. Punishment, reminders, or asking perceptions are less effective.

Question 5 of 5

The nurse is observing continuous cardiac monitoring for assigned clients. Which of the following cardiac rhythms would immediate follow-up?

Question Image

Correct Answer: C

Rationale: Ventricular fibrillation (VF) is a lethal dyshythmia characterized by disorganized electrical activity in the heart ventricles. Because
of this erratic electrical activity, the heart muscles lose the ability to contract, resulting in loss of blood flow and pulse (ie, cardiac
arrest). Nurses who identify a client with VF should immediately check the pulse, start CPR, and prepare the client for defibrillation

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