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Extract:

Intake and output record
Time Oral intake Parenteral intake Other intake Output
0700 150 mL vancomycin IV
0900 240 mL coffee 1500 mL dialysate
1100 120 mL tea
1300 100 mL cefepime IV 1400 mL dialysate outflow
1500 180 mL juice


Question 1 of 5

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

Correct Answer: 890

Rationale: Without specific intake/output data, a general approach is assumed: net fluid balance is calculated as total intake (IV, oral, etc.) minus total output (urine, emesis, etc.). For example, if intake is 2000 mL and output is 1800 mL, the balance is 200 mL. The nurse must sum all recorded values accurately.

Extract:


Question 2 of 5

The male client had a hemicolectomy. The client is refusing to wear the prescribed sequential compression devices (SCDs). What is most important for the nurse to communicate to the client?

Correct Answer: B

Rationale: SCDs prevent deep vein thrombosis (DVT) post-surgery, a potentially fatal complication. Communicating the risk of complications, including death (
B), is critical to emphasize the importance of compliance. Signing a refusal form (
A), billing (
C), or informing the surgeon (
D) are secondary to ensuring the client understands the serious risks.

Question 3 of 5

All nursing staff on the medical unit are responsible for implementing a new interdisciplinary fall prevention protocol. Which duties are appropriate for the licensed practical nurse to delegate to unlicensed assistive personnel to promote client safety? Select all that apply.

Correct Answer: B,C,D

Rationale: UAP can place commodes (
B), remind about slow position changes (
C), report condition changes (
D), and observe gait (E). Education (
A) requires nursing judgment, unsuitable for delegation.

Question 4 of 5

The nurse is to change a dressing. Which is essential to do when opening the dressing set?

Correct Answer: A

Rationale: The first flap should be opened away from the nurse to allow the last flap to be opened toward the nurse, preventing contamination. The dressing set should be placed at waist height on a clean surface like an overbed table, not on the bed or a chair.

Question 5 of 5

A client on hospice home care is taking sips of water but refusing food. Family members appear distressed and insist that the personal care worker 'force feed' the client. What is the priority nursing action?

Correct Answer: A

Rationale: Explaining that anorexia is normal in dying (
A) addresses family distress and aligns with hospice goals. Exploring concerns (
B) is secondary, feeding tubes (
C) are inappropriate, and choking warnings (
D) may escalate distress.

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