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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

A 2 month-old child has had a cleft lip repair. The selection of which restraint would require no further action by the charge nurse?

Correct Answer: A

Rationale: Elbow. The elbow restraint will prevent the child from touching the surgical site without hindering movement of other parts of the body.

Question 3 of 5

A young Spanish-speaking client is experiencing a spontaneous abortion (miscarriage). Which illustrates the best use of an interpreter to explain the situation to the client? Select all that apply.

Correct Answer: B,C,E

Rationale: A female interpreter respects cultural sensitivity, eye contact with the client fosters trust, and teaching one intervention at a time aids understanding. Friends/relatives as interpreters violate HIPAA.

Question 4 of 5

Which of the following musical instruments is best for a teen with asthma?

Correct Answer: A

Rationale: The guitar does not require breath control, making it suitable for a teen with asthma, unlike wind instruments like the clarinet.

Question 5 of 5

An adolescent client is admitted in respiratory alkalosis following aspirin overdose. The nurse recognizes that this imbalance was caused by

Correct Answer: A

Rationale: Tachypnea. Stimulation of respiratory center leads to hyperventilation, thus decreasing CO2 levels which causes respiratory alkalosis.

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